Free Small Claims Judgment - 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). )

SMALL CLAIMS JUDGMENT LIMITED GENERAL SUPPLEMENTAL Case No. _________________________

JUDGMENT is hereby given in favor of the judgment creditor(s) and against the judgment debtor(s) named in the money award below. Judgment is based on Plaintiff's Defendant's: failure to appear for a hearing on ______________________________. failure to comply with a mediated agreement (Affidavit of Noncomplianc attached) e JUDGMENT OF DISMISSAL is hereby entered: as to Plaintiff's claim, as to Defendant's counterclaim, on motion of Plaintiff ______________ _____ and Defendant ________________ ________ for want of prosecution, (Signature) (Signature) Plaintiff Defendant having failed to appear for hearing on ___________________. Other: _______________________________________________________________. Such judgment shall be: with prejudice without preju ice. d In addition to or in lieu of the money award below, this judgment establishes the following requirements: NONE or _______________________________________________. DATED: ________________ ________________________________________________ Circuit Court Judge / Deputy Court Administrator ________________________________________________ Print, Type or Stamp Name of Judge

MONEY AWARD 1. Judgment Creditor: _________________________________________________________________ 2. Judgment Creditor's Attorney: Noneor _____________________________________________
Name/Address/Phone No. Name(s)/Address

____________________________________________________________________________________ SMALL CLAIMS JUDGMENT ­ Page 1 of __

FC (11/20/08)

3. Judgment Debtor(s). Information for any additional debtor(s) is provided in attachments and incorporated herein by reference. a. Name: ______________________________ b. Name:_________________________________
The judgment creditor is responsible for providing information on items (4) through (9), to the extent known, if judgment lien status is desired and if the money award is at least $3,000 (not including costs and fees). Items (5) through (10) are not required for money awards of $10 or more and less than $3,000, not including costs and disbursements. Additional fees may be required to create a lien.

4a. Address: ______________________________ 4b. Address:_______________________________ 5a. DOB: _________________________________ 5b. DOB: _________________________________ 6a. SSN or Tax ID: ______________________ 7a. Dr. Lic. No./State: ____________________ 6b. SSN or Tax ID: _________________________ 7b. Dr. Lic. No./State: _______________________

8. Judgment Debtor's Attorney: None, OR _____________________________________________. Name 9. Person or public body entitled to a portion of the money award: NO ONE or _______________ ____________________________________________________________________________________ 10. Money award of $___________ 11. Prejudgment interest information:____________________________________________________ 12. Post judgment interest information: __________________________________________________ 13. Accrued arrearages of $___________ 14. Costs and service expenses of $___________ 15. Prevailing party fee of $___________ Total Money Award: $___________ DEFERRED FEES 1a. Judgment Creditor: STATE OF OREGON 2a. Judgment Debtor:______________________ 3a. Amount: $___________ DATED: ________________ 1b. Judgment Creditor: STATE OF OREGON 2b. Judgment Debtor: _______________________ 3b. Amount: $___________ ________________________________________________ Circuit Court Judge / Deputy Court Administrator ________________________________________________ Print, Type or Stamp Name of Judge SMALL CLAIMS JUDGMENT ­ Page 2 of 2 FC (11/20/08)