Free Microsoft Word - LACIV 215 New 09-08 - California

NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY:

STATE BAR NUMBER

Reserved for Clerk's File Stamp

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES
COURTHOUSE ADDRESS: PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT:

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CASE NUMBER:

REQUEST FOR ENTRY OF JUDGMENT, JUDGMENT, AND NOTICE OF ENTRY OF JUDGMENT ­ LABOR CODE SECTION 5806 AND ISSUANCE OF A WRIT OF EXECUTION AND/OR OTHER ENFORCEMENT
REQUEST FOR ENTRY OF JUDGMENT The Clerk of the Court is requested to enter judgment in favor of: Plaintiff(s) Defendant(s) , pursuant to the

Against Plaintiff(s) Defendant(s) Labor Code section 5806 as follows: a. b. c. d. e. f. g. Principal.................................................................................. $ Attorney Fees........................................................................... $ Costs (including civil filing fee and administrative charge).................. $ Amount of judgment requested .....................................................$ Prejudgment interest of the annual rate for % ...............$

Total judgment requested ........................................................... $ Plus interest after judgment at the legal rate.

A certified copy of the Order Approving Compromise & Release form of the Division of Workers Compensation is attached.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Dated:

By:

Attorney for

LACIV 215 (New)

LASC Approved 09-08

REQUEST FOR ENTRY OF JUDGMENT, JUDGMENT, AND NOTICE OF ENTRY OF JUDGMENT LABOR CODE SECTION 5806

Labor Code,§ § 5806, 5811 Page 1 of 2

PLAINTIFF/PETITIONER (Name): DEFENDANT/RESPONDENT (Name):

CASE NUMBER

JUDGMENT AND NOTICE OF ENTRY OF JUDGMENT Judgment entered in favor of: Plaintiff(s) Against Defendant(s) Defendant(s)

Plaintiff(s) a. b. c. d. e. f. g.

Principal.................................................................................. $ Attorney Fees........................................................................... $ Costs granted by the Appeals Board . . . . . . . . . .............................. $ Amount of judgment requested .....................................................$ Prejudgment interest of the annual rate for % ...............$

Total judgment requested ........................................................... $ Plus interest after judgment at the legal rate.

Judgment entered on

.

Dated:

JOHN A. CLARKE, Executive Officer/Clerk

By: Deputy Clerk

CERTIFICATE OF MAILING

I, the below-named Executive Officer/Clerk of the above-entitled court, do hereby certify that I am not a party to the cause herein, and that on this date I served the Request for Entry of Judgment, Judgment, and Notice of Entry of Judgment ­ Labor Code section 5806 upon each party or counsel named below by depositing in the United States mail at the courthouse in , California, one copy of the original filed/entered herein in a

separate sealed envelope to each address as shown below with postage thereon fully prepaid.

JOHN A. CLARKE, Executive Officer/Clerk By:
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Deputy Clerk

LACIV 215 (New)

LASC Approved 09-08 Print This Form

REQUEST FOR ENTRY OF JUDGMENT, JUDGMENT, Labor Code,§ § 5806, 5811 AND NOTICE OF ENTRY OF JUDGMENT LABOR CODE SECTION 5806 Page 2 of 2 Clear This Form