$500

$500

ACKNOWLEDGEMENT OF AN ISSUE OF CURRENCY

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IN THE CIRCUIT COURT FOR THE STATE OF OREGON
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CAPITAL ONE BANK

Plaintiff
vs.
MARY SMITH
Defendant

For the County of Multnomah

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COMPLAINT FOR MONEY OWED
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Case No. 1234
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COMPLAINT FOR MONEY OWED

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etc., etc., etc.
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ACCEPTED FOR VALUE BY DRAWEE

THIS IS AN ISSUE OF CURRENCY FOR CAUSE
Deposit to the United States Treasury and charge the same to:
John H. Smith , CLERK OF THE COURT
CIRCUIT COURT FOR THE STATE OF OREGON, MULTNOMAH COUNTY
123 Main Street, suite #200
Anytown, Oregon, 97123

By: ____________________________ , DRAWEE

All rights reserved and subrogated to US Treasury

$500

FIVE HUNDRED DOLLARS

VOID WHERE PROHIBITED BY LAW

$500