COMPLAINT ON A PROMISSORY NOTE

1. Allegation of jurisdiction.

2. Defendant on or about June 1,1935,executed and delivered to plaintiff a promissory note[in the following words and figures（here set out the note verbatim）];[a copy of which is hereto annexed as Exhibit A]; [whereby defendant promised to pay to plaintiff or order on June 1,1936 the sum of __________dollars with interest thereon at the rate of six percent per annum].

3. Defendant owes to plaintiff the amount of said note and interest.

Wherefore plaintiff demands judgment against defendant for the sum of _________ dollars, interest, and costs.

Signed: ___________

Attorney for Plaintiff

Address: __________