Free Form 15.010.1b - 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 DEFAULT JUDGMENT; DEFENDANT STATUS AFFIDAVIT

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

request default 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: NONE, or I have attached a completed proposed small claims judgment for purposes of this request. In furtherance of this request, I state that: 1. The above-named defendant(s) was duly and regularly served with a copy of the claim and failed to pay the claim or demand a hearing or trial within 14 days; 2. The person against whom I seek judgment by this request: (a) is not one of the following defined by ORS 125.005 and protected by ORCP 69 B: a minor, incapacitated, a protected person, or a respondent; (b) G is G is not G I am unable to determine whether this person is a person protected by the Servicemembers Civil Relief Act (50 U.S.C. App. 501 to 596). The facts that support this statement are: 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 15.010.1b ­ REQUEST FOR DEFAULT JUDGMENT; DEFENDANT STATUS AFFIDAVIT ­ UTCR 15.010(1)(b) (Revised 8-1-05)

UTCR App. Page 44