E-FILED 2014 SEP 04 4:05 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)

City of Wall Lake

_______________________________________
(Name)

_______________________________________
(Name)

Defendant(s)

vs.

Verification of Account,
Identification of Judgment
Debtor, and Certificate
Re Military Service
Small Claim No. _____________________

The Haye Loft

_______________________________________
(Name)

_______________________________________
(Name)

For Defendant: __________________________

(This form required for each Defendant.)

Lynn Grosely
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
1168.79
showing the balance due is true and correct. I further state that the sum of $__________
is the
September 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.
303 E 5th St. Wall Lake, IA. 51466
2. I further state that Defendant resides at __________________________________________,
Cookies Food Products
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.

September 4, 2014
Date:__________________________________
712-664-2216
_______________________________________
Phone #
citywl1@netins.net
_______________________________________
EMail adress
_______________________________________
Additional email address, if appilcable

_______________________________________
Signature of Affiant
Lynn Grosely
/s/_____________________________________
Filing Plaintiff or Attorney
City of Wall Lake
_______________________________________
Law firm, or entity for which filing is made, if applicable

P.O. Box 37 Wall Lake, IA. 51466

_______________________________________
Mailing Address

E-FILED 2014 SEP 04 4:05 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)

City of Wall Lake

_______________________________________
(Name)

_______________________________________
(Name)

Defendant(s)

vs.

Verification of Account,
Identification of Judgment
Debtor, and Certificate
Re Military Service
Small Claim No. _____________________

The Haye Loft

_______________________________________
(Name)

_______________________________________
(Name)

For Defendant: __________________________

(This form required for each Defendant.)

Lynn Grosely
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
1168.79
showing the balance due is true and correct. I further state that the sum of $__________
is the
September 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.
303 E 5th St. Wall Lake, IA. 51466
2. I further state that Defendant resides at __________________________________________,
Cookies Food Products
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.

September 4, 2014
Date:__________________________________
712-664-2216
_______________________________________
Phone #
citywl1@netins.net
_______________________________________
EMail adress
_______________________________________
Additional email address, if appilcable

_______________________________________
Signature of Affiant
Lynn Grosely
/s/_____________________________________
Filing Plaintiff or Attorney
City of Wall Lake
_______________________________________
Law firm, or entity for which filing is made, if applicable

P.O. Box 37 Wall Lake, IA. 51466

_______________________________________
Mailing Address

Page 1 of 1

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9/25/2014

E-FILED 2014 OCT 15 9:15 AM SAC - CLERK OF DISTRICT COURT

IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY

Plaintiff(s),
CITY OF WALL LAKE OTHER PIN
CITY OFFICES
PO BOX 37
WALL LAKE IA 51466

SMALL CLAIMS DIVISION

Case: 02811 SCSC015500

vs.
JUDGMENT ENTRY
Defendant(s),
HAYE LOFT
PO BOX 64
130 W 1ST ST
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 $ 2120.86 with interest at the rate of 2.11 % from the 4th day of September, 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: $2200.00

1 of 2

E-FILED 2014 OCT 15 9:15 AM SAC - CLERK OF DISTRICT COURT

State of Iowa Courts

Case Number
SCSC015500
Type:

Case Title
CITY OF WALL LAKE VS THE HAYE LOFT
ORDER FOR JUDGMENT
So Ordered

Electronically signed on 2014-10-15 09:15:11

2 of 2