Prepared By:
JOHN DOE, #1234
ATTORNEY AT LAW, P.A.
200 SE 7 ST
TOPEKA, KS  66603
(785) 233-8200
Attorney for Plaintiff




              IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS
                         LIMITED ACTIONS DIVISION



EAT AT JOE'S                                       ) Plaintiff
                                                   )
              vs.                                  ) Case Number 99L 000001
                                                   ) Division No. 09
JOHN Q. PUBLIC                                     ) Defendant(s)
123 NW ANY ST                                      )
TOPEKA, (SHAWNEE County), KS  66601                )

Service By: Certified Mail

                              P E T I T I O N
                             (worthless check)

The plaintiff states the following claim(s):

1. That the defendant(s) gave one or more worthless checks as defined by law.

2. That plaintiff is the holder of said check(s) and has made proper written demand upon 
defendant for payment as required by law pursuant to K.S.A. 60-2610.  More than fourteen (14) 
days have passed thereafter without payment by the defendant(s).

                                  COUNT 1

3.1. That pursuant to K.S.A. 60-2610, plaintiff is entitled to judgment against the defendant(s) 
for the amount of the check(s) in the amount of $50.00, statutory damages in the amount of 
$150.00, incurred service charges of $30.00, the costs of restricted mail in the amount of 
$5.73, and reasonable attorney fees in the amount of $345.00, and any additional attorney fees 
ordered by the court.

                                  COUNT 2

3.2. That pursuant to K.S.A. 60-2610, plaintiff is entitled to judgment against the defendant(s) 
for the amount of the check(s) in the amount of $50.00, statutory damages in the amount of 
$150.00, incurred service charges of $30.00, and any additional attorney fees ordered by the 
court.

                                  COUNT 3

3.3. That pursuant to K.S.A. 60-2610, plaintiff is entitled to judgment against the defendant(s) 
for the amount of the check(s) in the amount of $50.00, statutory damages in the amount of 
$150.00, incurred service charges of $30.00, and any additional attorney fees ordered by the 
court.

                                  COUNT 4

3.4. That pursuant to K.S.A. 60-2610, plaintiff is entitled to judgment against the defendant(s) 
for the amount of the check(s) in the amount of $40.00, statutory damages in the amount of 
$120.00, incurred service charges of $30.00, and any additional attorney fees ordered by the 
court.

4. That defendant(s) may, prior to the commencement of a dispositional hearing by the Court, 
tender to plaintiff as satisfaction of the claim an amount of money equal to $700.23 which 
amount is equal to the sum of the amount of the check(s), the incurred court costs, 
service charge, costs of restricted mail and the costs of collection, including but not 
limited to reasonable attorney fees.

     WHEREFORE, Plaintiff demands judgment against the defendant(s) for:

          FACE AMOUNT OF CHECK(S)         $     190.00
          SERVICE CHARGE                  $     120.00
          RESTRICTED MAIL COSTS           $       5.73
          STATUTORY DAMAGES               $     570.00
          ATTORNEY FEES                   $     345.00
                                          __________________
for a total of                            $   1,230.73

plus interest after judgment at the statutory rate per year, and court costs.




                                              _____________________________
                                                            JOHN DOE, #1234

**This is a communication from a debt collector.  This is an attempt to
collect a debt and any information obtained will be used for that purpose
only.**

(ckpsnks 01-2001)

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