1.管辖权声明。

　　2.被告于或大约于1935年6月1日签署并交付原告本票一张[以下述文字与数字作成：（在此逐字抄录）]；[该本票副本见附件证据A]；[因此被告于1936年6月1日承诺支付或指示支付原告___________美元并附加年利息率为6%].

　　3.被告欠原告该本票所载款项及利息。

　　据此，原告请求判决被告偿付________美元的款项、利息及费用。

　　签名：___________

　　原告律师

　　地址；_____________

　　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： __________