Free Noncompliance Affidavit - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE THIRD JUDICIAL DISTRICT Small Claims Division - P.O. Box 12869, Salem, OR 97309 _________________________________, Plaintiff, vs. _________________________________, _________________________________, Defendant(s). ) ) ) ) ) ) )

REQUEST FOR JUDGMENT; NONCOMPLIANCE AFFIDAVIT Case No. _________________________

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

I, _________________________ request judgment against ______________________ in the following amount: (your name) (other party's name) _______________________, based on: __________________________________________________________ __________________________________________________________________________________________ I request judgment include postjudgment interest at the rate of 9% per annum (or) _______ % 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. I, _________________________, hereby swear or affirm that on _______________ _______________________ (your name) (date) (other party's name) and I signed a Mediation Agreement which has been entered in this case and which contained the following terms: _____________________________________________________________________________________ ___________________________________________________________________________________________ has not complied with the agreement by failing to do the following: ___ (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) __________________________________________________________________________________________ Plaintiff's Defendant's Name (print) Authorized Signature Dated SUBSCRIBED AND SWORN to before me this __________day of ____________________, 200_____. NOTARY PUBLIC FOR OREGON/COURT ADMINISTRATOR __________________________________________________ My Commission expires: _____________________________

REQUEST FOR DEFAULT JUDGMENT; DEFENDANT STATUS AFFIDAVIT - Page 1 of 1 FC(12/16/03)