COMMONWEALTH OF MASSACHUSETTS
________________,SS: HOUSING COURT DEPARTMENT _______________ DIVISION / / / - / / / / / / SMALL CLAIMS NO.
STATEMENT OF FAILURE TO COMPLY WITH RULE 7(G) (Please print clearly or type)
I, ___________________________________________________________________ (First Name) (MI.) (Last Name) (If Corporation or Trust,
list name of principal officer and title)
the prevailing party in the action, residing at: _____________________________________________________________________ (No.) (Address) (City/Town) ______________________________________ (State) (Zip Code) state that __________________ (First Name)
_____________________________________________________________________ (MI.) (Last Name) (If Corporation/Trust list name of principal
residing at __________________________________________________________ (No.) (Address) (City/Town) (State) (Zip) the respondent, has failed to obey the order of payment. I request further that this Court make appropriate orders to ensure compliance with the order of payment, and order the respondent to pay my costs of service. Signed under the pains and penalties of perjury this _________________ day of ____________________ 20_____.
________________________________ (Prevailing Party) ________________________________ ________________________________ ________________________________ ________________________________