On February 15, 2024 a
Party Statement
was filed
involving a dispute between
Northwoods Credit Union,
and
Kane, Zachariah Carlbloom,
for Conciliation
in the District Court of Carlton County.
Preview
09-CO-24-85
Filed in District Court
State of Minnesota
2/15/2024 1:43 PM
State of Minnesota Conciliation Court
County of: Judicial District: Sixth
Carlton Court File Number:
Case Type: Conciliation
PLAINTIFF 'S STATEMENT 0F CLAIM
Plaintiff #1 Plaintiff #2
Name: Northwoods Credit Union Name:
Address: P0 Box 489 Address:
City/State/Zip Moose Lake, MN 55767 City/State/Zip:
Defendant #1 Defendant #2
Name: Zachariah Kane Name:
Address: 4511 Jean Duluth Rd. Address:
City/State/Zip: Holyoke, MN 55749 City/State/Zip
D Check box if there are more than two plaintiffs or more than two defendants. List the
information for the other parties on the Additional Litigants Farm, CCT702.
Information about the Defendant
1. How many defendants are there? 1
a. Defendant # l
Name: Zachariah Kane
Individual (Person) D Business
ifDefendant # I is an fndividual.'
i. I believe Defendant #1 is at least 18 years old.
Date of birth: 05/21 /'| 985 / DUnknown.
ii. About military service:
D Defendant #1 is in the military service
D Defendant #1 is not in the military service
Unknown.
b. Defendant # 2
Name:
Individual (Person) DBusiness
IfDefiandant # 2 is an individual.'
i. I believe Defendant #2 is at least 18 years old.
Plaintiffs Statement of Claim
CCT102 State ENG Rev 10/20 www.mncourtsgovtforms Page 1 of3
09-CO-24-85
Filed in District Court
State of Minnesota
2/15/2024 1:43 PM
Date of birth: / D Unknown.
ii. About military service:
D Defendant # 2 is in the military service
D Defendant # 2 is not in the military service
Unknown.
If there are more than 2 defendants, use the Additional Litigants Farm (CCT702).
Information about the-Claim
2. I am filing this claim against Defendant for: (check all that appbz)
Money
The Defendant owes me $ 2,724.87 , plus filing fees and costs in the amount of
$ 80.00 $
, so my total claim is for 2,804.87 (amount Defendant owes
plus filing fees and costs). I have a claim for this amount because in
August, 2023 (month and year), the following happened (briefly describe):
The defendant defaulted on his Visa Credit Card. The defendant is unwilling to work with
us at this time.
Properg'
D The Defendant has the following property that belongs to me (list property):
My property is valued at $ . The filing fees and costs for this case are
$ . I want the court to order this property returned to me or make the
Defendant pay me $ (property's value plus the filing fees and costs).
3. I understand that if I do not come to court on my hearing date, my case may be dismissed and
I may have to pay money to the Defendant on any counterclaim that has been filed.
Plaintiff's Statement of Claim
CCT102 State ENG Rev 10/20 www.mncourts.govlfonns Page 2 of 3
09-CO-24-85
Filed in District Court
State of Minnesota
2/15/2024 1:43 PM
Important! Each plaintiff must sign the Statement of Claim form and include the date signed,
the name of the state and county where signed, and provide the following information: title, if
any, telephone number, date of birth, and email address.
I declare under penalty of perjury that everything thatI have stated in this document is true and
correct. Minn. Stat. § 358.116.
Signature (Plaintiff #1) Signature (Plaintiff #2)
OR DThere is only l plaintiff
DATE: 02/08/2024 D ATE:
Carlton Minnesota
County and State where signed County and State Where signed
Alexis Karsky
Name Name
Member Solutions Specialist
Title, if any Title, if any
21 8-878-3962
Telephone Telephone
12/16/2002
Date of birth Date of birth
alexisb@northwoodscu.org
Email Address Email Address
NOTE: If there are more than 2 plaintiffs, all of the other plaintiffs must sign the Statement of
Claim form and include the information listed above.
Plaintifis Statement of Claim
CCT102 State ENG Rev 10/20 www.mncourts.govlforms Page 3 of 3
09-CO-24-85
Filed in District Court
State of Minnesota
2/15/2024 1:43 PM
MOOSE LAKE BRANCH
90 Arrowhead Lane
PO Box 489. Moose Lake. MN 55767
NOFEHWOOdS Phone (218) 4855707
CREDIT UNION T011 Free (888) 458-0975
Loans Given. Dreams Rea/lbed.
POWER OF ATTORNEY
This letter shall constitute a Power of Attorney, by which Northwoods Credit Union, on behalf of itself and as
agent for certain of its affiliates, hereby appoints Alexis Karsky as its designee to represent Northwoods Credit
Union as the plaintiff in any small claims or District Court cases regarding credit transaction defaults.
Northwoods Credit Union
By
Terry Burn, Senior Vice President -
Chief Lending Officer
Subscribed and sworn to before me
BRAND! [EN BANDEL
'
is 18th a f Januag ,2024 NOTARY PUBLIC
/ MINNESOTA
I
\ .
6-. Expires Jan. 31. 2027
MyvComnission
Notary Public
Offices at: 1702 Avenue B, Cloquet 902 Stanley Avenue. Cloquet
-
90 Arrowhead Lane. Moose Lake 224 W Highway 2, Floodwood
-
www.northwoodscu.org
Document Filed Date
February 15, 2024
Case Filing Date
February 15, 2024
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Preview
09-CO-24-85 Filed in District Court State of Minnesota 2/15/2024 1:43 PM State of Minnesota Conciliation Court County of: Judicial District: Sixth Carlton Court File Number: Case Type: Conciliation PLAINTIFF 'S STATEMENT 0F CLAIM Plaintiff #1 Plaintiff #2 Name: Northwoods Credit Union Name: Address: P0 Box 489 Address: City/State/Zip Moose Lake, MN 55767 City/State/Zip: Defendant #1 Defendant #2 Name: Zachariah Kane Name: Address: 4511 Jean Duluth Rd. Address: City/State/Zip: Holyoke, MN 55749 City/State/Zip D Check box if there are more than two plaintiffs or more than two defendants. List the information for the other parties on the Additional Litigants Farm, CCT702. Information about the Defendant 1. How many defendants are there? 1 a. Defendant # l Name: Zachariah Kane Individual (Person) D Business ifDefendant # I is an fndividual.' i. I believe Defendant #1 is at least 18 years old. Date of birth: 05/21 /'| 985 / DUnknown. ii. About military service: D Defendant #1 is in the military service D Defendant #1 is not in the military service Unknown. b. Defendant # 2 Name: Individual (Person) DBusiness IfDefiandant # 2 is an individual.' i. I believe Defendant #2 is at least 18 years old. Plaintiffs Statement of Claim CCT102 State ENG Rev 10/20 www.mncourtsgovtforms Page 1 of3 09-CO-24-85 Filed in District Court State of Minnesota 2/15/2024 1:43 PM Date of birth: / D Unknown. ii. About military service: D Defendant # 2 is in the military service D Defendant # 2 is not in the military service Unknown. If there are more than 2 defendants, use the Additional Litigants Farm (CCT702). Information about the-Claim 2. I am filing this claim against Defendant for: (check all that appbz) Money The Defendant owes me $ 2,724.87 , plus filing fees and costs in the amount of $ 80.00 $ , so my total claim is for 2,804.87 (amount Defendant owes plus filing fees and costs). I have a claim for this amount because in August, 2023 (month and year), the following happened (briefly describe): The defendant defaulted on his Visa Credit Card. The defendant is unwilling to work with us at this time. Properg' D The Defendant has the following property that belongs to me (list property): My property is valued at $ . The filing fees and costs for this case are $ . I want the court to order this property returned to me or make the Defendant pay me $ (property's value plus the filing fees and costs). 3. I understand that if I do not come to court on my hearing date, my case may be dismissed and I may have to pay money to the Defendant on any counterclaim that has been filed. Plaintiff's Statement of Claim CCT102 State ENG Rev 10/20 www.mncourts.govlfonns Page 2 of 3 09-CO-24-85 Filed in District Court State of Minnesota 2/15/2024 1:43 PM Important! Each plaintiff must sign the Statement of Claim form and include the date signed, the name of the state and county where signed, and provide the following information: title, if any, telephone number, date of birth, and email address. I declare under penalty of perjury that everything thatI have stated in this document is true and correct. Minn. Stat. § 358.116. Signature (Plaintiff #1) Signature (Plaintiff #2) OR DThere is only l plaintiff DATE: 02/08/2024 D ATE: Carlton Minnesota County and State where signed County and State Where signed Alexis Karsky Name Name Member Solutions Specialist Title, if any Title, if any 21 8-878-3962 Telephone Telephone 12/16/2002 Date of birth Date of birth alexisb@northwoodscu.org Email Address Email Address NOTE: If there are more than 2 plaintiffs, all of the other plaintiffs must sign the Statement of Claim form and include the information listed above. Plaintifis Statement of Claim CCT102 State ENG Rev 10/20 www.mncourts.govlforms Page 3 of 3 09-CO-24-85 Filed in District Court State of Minnesota 2/15/2024 1:43 PM MOOSE LAKE BRANCH 90 Arrowhead Lane PO Box 489. Moose Lake. MN 55767 NOFEHWOOdS Phone (218) 4855707 CREDIT UNION T011 Free (888) 458-0975 Loans Given. Dreams Rea/lbed. POWER OF ATTORNEY This letter shall constitute a Power of Attorney, by which Northwoods Credit Union, on behalf of itself and as agent for certain of its affiliates, hereby appoints Alexis Karsky as its designee to represent Northwoods Credit Union as the plaintiff in any small claims or District Court cases regarding credit transaction defaults. Northwoods Credit Union By Terry Burn, Senior Vice President - Chief Lending Officer Subscribed and sworn to before me BRAND! [EN BANDEL ' is 18th a f Januag ,2024 NOTARY PUBLIC / MINNESOTA I \ . 6-. Expires Jan. 31. 2027 MyvComnission Notary Public Offices at: 1702 Avenue B, Cloquet 902 Stanley Avenue. Cloquet - 90 Arrowhead Lane. Moose Lake 224 W Highway 2, Floodwood - www.northwoodscu.org