Free Form 15.010.1c - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY Small Claims Division - _____________________________________________________
(court's address and phone number)

Plaintiff

v.

Defendant(s)

) ) ) ) ) ) ) )

CASE No. _________________ REQUEST FOR JUDGMENT; NONCOMPLIANCE AFFIDAVIT

(NOTE: Complete this and attach a completed Judgment you propose) I,
Name

request judgment against
Other Party's Name

for the following : A total judgment award of $ , which total includes: 1. A money award of $ , 2. Prejudgment interest of $ , 3. Accrued arrearages of $ , if any, 4. Costs and service expenses of $ , 5. A prevailing party fee under ORS 20.190 of $ I request judgment include postjudgment interest at a rate of % per based on
(authority for interest)

And, I request the following terms in addition to or in lieu of a money award: G NONE, or I have attached a completed proposed small claims judgment for purposes of this request. I, ___________________________________, hereby swear or affirm that on ____________________________
(date agreement signed)

____________________________________ and I signed a Mediation Agreement which has been entered
(Print other party's name)

in this case and which contained the following terms. ________________________________________________ __________________________________________________________________________________________ _____________________________________ has not complied with the agreement by failing to do the following:
(print other party's name)

__________________________________________________________________________________________ __________________________________________________________________________________________ I did not keep the other party from following the agreement. I certify that on I mailed a copy
(date)

of this request to the party against whom I request judgment at
(address)

I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Plaintiff's Name (print) Dated: _______________________________ _____________________________________________ Authorized Signature

Form 15.010.1c ­ REQUEST FOR JUDGMENT; NONCOMPLIANCE AFFIDAVIT ­ UTCR 15.010(1)(c) (Revised 8-1-05)

UTCR App. Page 45