E-FILED 2014 NOV 28 1:37 PM SAC - CLERK OF DISTRICT COURT

eForm 3.1: Original Notice and Petition for a Money Judgment

SAC
In the Iowa District Court for ________________
County
Plaintiff(s)
CBSI, INC.
________________________________________
(Name)

Original Notice and Petition

for a Money Judgment

PO BOX 180 OSKALOOSA, IA 52577

________________________________________
(Address)

________________________________________
(Name)

________________________________________
(Address)

vs.
Defendant(s)
AMY BRYANT
________________________________________

(Name)

204 E. 3RD ST. WALL LAKE, IA 51466

________________________________________
(Address)

CHRIS BRYANT
________________________________________
(Name)

204 E. 3RD ST. WALL LAKE, IA 51466

________________________________________
(Address)

To Defendant(s):

948.00
1. You are notified that Plaintiff(s) demand(s) from you the amount of $ ______________
plus court
costs based on (state briefly the basis for the demand, not to exceed $5000):
DENTAL ACCOUNT

2. Judgment may be entered against you unless you file an Appearance and Answer within 20 days
of the service of the Original Notice upon you. Judgment may include the amount requested plus interest
and court costs.
3. You must electronically file the Appearance and Answer using the Iowa Judicial Branch Electronic
Document Management System (EDMS) at https://www.iowacourts.state.ia.us/EFile, unless you obtain
from the court an exemption from electronic filing requirements.
4. If your Appearance and Answer is filed within 20 days and you deny the claim, you will receive
electronic notification through EDMS of the place and time of the hearing on this matter.
5. If you electronically file, EDMS will serve a copy of the Appearance and Answer on Plaintiff(s) or on the
attorney(s) for Plaintiff(s). The Notice of Electronic Filing will indicate if Plaintiff(s) is (are) exempt from electronic filing, and if you must mail a copy of your Appearance and Answer to Plaintiff(s).
6. You must also notify the clerks office of any address change.

ERIC PALMER
/s/ ________________________________

/s/ ________________________________

CBSI, INC.
___________________________________

___________________________________

Filing Plaintiff or Attorney

Law firm, or entity for which filing is made, if applicable

Second Plaintiff, if applicable

Law firm, or entity for which filing is made, if applicable

eForm 3.1, page 1 of 3

E-FILED 2014 NOV 28 1:37 PM SAC - CLERK OF DISTRICT COURT

PO BOX 180 OSKALOOSA, IOWA 52577

___________________________________

___________________________________

6416739427
___________________________________

___________________________________

rcallison@creditiowa.com
___________________________________

___________________________________

___________________________________

___________________________________

Mailing address

Telephone number
Email address

Additional email address, if applicable

Mailing address

Telephone number
Email address

Additional email address, if applicable

eForm 3.1, page 2 of 3

E-FILED 2014 NOV 28 1:37 PM SAC - CLERK OF DISTRICT COURT

eForm 3.27: Verification of Account, Identification of Judgment Debtor, and Certificate Re Military
Service

SAC
In the Iowa District Court for ________________
County

Plaintiff(s)

Verification of Account,
Identification of Judgment
Debtor, and Certificate
Re Military Service

CBSI, INC.
_______________________________________
(Name)

_______________________________________
(Name)

Defendant(s)

vs.

Small Claim No. _____________________

AMY BRYANT
_______________________________________
(Name)

CHRIS BRYANT
_______________________________________
(Name)

AMY BRYANT
For Defendant: __________________________
(This form required for each Defendant.)

ERIC PALMER
1. I, ______________________________________________,
am a party or an employee of
Plaintiff(s) whose claim(s) is (are) shown in the attached statement(s). I have personal
knowledge that the attached statement(s) is (are) a true copy of the original creditors records
948.00
showing the balance due is true and correct. I further state that the sum of $__________
is the
11/28/2014
balance due and owing as of ____________________________
from Defendant(s) to Plaintiff(s)
and any interest amount owing is accurately stated in the Petition or Original Notice.
204 E. 3RD ST. WALL LAKE, IA 51466
2. I further state that Defendant resides at __________________________________________,
PARKVIEW REHABILITATION
is employed at _________________________________________________________________,
and Defendants occupation is ____________________________________________________.
3. Check A, B, or C for Defendant:
A.
Defendant is not in the military service of the United States government, I have
verified this fact by (check one):
Checking the Defense Manpower Data Center (DMDC) (requires name and SSN
or name and date of birth) at https://www.dmdc.osd.mil/appj/scra/scraHome.do.
Contacting Defendant who informed me.
Regularly seeing Defendant and believing Defendant is not active in the U.S.
military.
OR
B.
I have investigated, and I am unable to determine whether or not Defendant is in
the military service of the United States government.
OR
C.
Defendant is in the military service of the United States government.
4. I also state to the best of my knowledge (check one):
Defendant
is
is not under a disability or confined in a reformatory, jail, or
penitentiary.
I certify under penalty of perjury and pursuant to the laws of the State of Iowa that these facts are
true and correct.

11/28/14
Date:__________________________________
6416739427
_______________________________________
Phone #
rcallison@creditiowa.com
_______________________________________
EMail adress
_______________________________________
Additional email address, if appilcable

_______________________________________
Signature of Affiant
ERIC PALMER
/s/_____________________________________
Filing Plaintiff or Attorney
CBSI,
INC.
_______________________________________
Law firm, or entity for which filing is made, if applicable

PO
BOX 180 OSKALOOSA, IOWA 52577
_______________________________________
Mailing Address

E-FILED 2014 NOV 28 1:37 PM SAC - CLERK OF DISTRICT COURT

eForm 3.27: Verification of Account, Identification of Judgment Debtor, and Certificate Re Military
Service

SAC
In the Iowa District Court for ________________
County

Plaintiff(s)

Verification of Account,
Identification of Judgment
Debtor, and Certificate
Re Military Service

CBSI, INC.
_______________________________________
(Name)

_______________________________________
(Name)

Defendant(s)

vs.

Small Claim No. _____________________

AMY BRYANT
_______________________________________
(Name)

CHRIS BRYANT
_______________________________________
(Name)

CHRIS BRYANT
For Defendant: __________________________
(This form required for each Defendant.)

ERIC PALMER
1. I, ______________________________________________,
am a party or an employee of
Plaintiff(s) whose claim(s) is (are) shown in the attached statement(s). I have personal
knowledge that the attached statement(s) is (are) a true copy of the original creditors records
948.00
showing the balance due is true and correct. I further state that the sum of $__________
is the
11/28/2014
balance due and owing as of ____________________________
from Defendant(s) to Plaintiff(s)
and any interest amount owing is accurately stated in the Petition or Original Notice.
204 E. 3RD ST. WALL LAKE, IA 51466
2. I further state that Defendant resides at __________________________________________,
is employed at _________________________________________________________________,
and Defendants occupation is ____________________________________________________.
3. Check A, B, or C for Defendant:
A.
Defendant is not in the military service of the United States government, I have
verified this fact by (check one):
Checking the Defense Manpower Data Center (DMDC) (requires name and SSN
or name and date of birth) at https://www.dmdc.osd.mil/appj/scra/scraHome.do.
Contacting Defendant who informed me.
Regularly seeing Defendant and believing Defendant is not active in the U.S.
military.
OR
B.
I have investigated, and I am unable to determine whether or not Defendant is in
the military service of the United States government.
OR
C.
Defendant is in the military service of the United States government.
4. I also state to the best of my knowledge (check one):
Defendant
is
is not under a disability or confined in a reformatory, jail, or
penitentiary.
I certify under penalty of perjury and pursuant to the laws of the State of Iowa that these facts are
true and correct.

11/28/14
Date:__________________________________
6416739427
_______________________________________
Phone #
rcallison@creditiowa.com
_______________________________________
EMail adress
_______________________________________
Additional email address, if appilcable

_______________________________________
Signature of Affiant
ERIC PALMER
/s/_____________________________________
Filing Plaintiff or Attorney
CBSI,
INC.
_______________________________________
Law firm, or entity for which filing is made, if applicable

PO
BOX 180 OSKALOOSA, IOWA 52577
_______________________________________
Mailing Address

E-FILED 2014 DEC 12 1:53 PM SAC - CLERK OF DISTRICT COURT

E-FILED 2014 DEC 29 9:25 AM SAC - CLERK OF DISTRICT COURT

IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY

Plaintiff(s),
CBSI, INC
1306 S 7TH ST
PO BOX 180
OSKALOOSA IA 52577

SMALL CLAIMS DIVISION

Case: 02811 SCSC015547

vs.
JUDGMENT ENTRY
Defendant(s),
AMY LOU BRYANT
BOX 253
WALL LAKE IA 51466
CHRIS BRYANT
204 E 3RD ST PO BOX 253
WALL LAKE IA 51466

The court file shows that the defendant has received proper notice and has failed to answer. The
relief is readily ascertainable from the Original Notice. Pursuant to Iowa Code Section 631.5(6), the
defendant is in default and judgment should enter accordingly.
It is therefore Ordered that judgment is entered in favor of the plaintiff and against the defendant in
the amount of $ 948.00 with interest at the rate of 2.13 % from the 28th day of November, 2014 and
court costs.

YOU ARE HEREBY NOTIFIED that you have a right to appeal the decision to the District Court by
giving written notice to the Small Claims Office within 20 days of the filing of this order. Filing Fee for
appeal is $185.00. Appeal Bond is set in the amount of: $1000.00

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E-FILED 2014 DEC 29 9:25 AM SAC - CLERK OF DISTRICT COURT

State of Iowa Courts

Case Number
SCSC015547
Type:

Case Title
CBSI, INC. VS. AMY & CHRIS BRYANT
ORDER FOR JUDGMENT
So Ordered

Electronically signed on 2014-12-29 09:25:26

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