STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT AFFIDAVIT AND REQUEST FOR ENTRY OF DEFAULT Plaintiff Civil Action File Number Defendant Murray Judicial Complex Newport County 45 Washington Square Newport, Rhode Island 02840-2913 (401) 841-8330 McGrath Judicial Complex Washington County 4800 Tower Hill Road Wakefield, Rhode Island 02879-2239 (401) 782-4121 Noel Judicial Complex Kent County 222 Quaker Lane Warwick, Rhode Island 02886-0107 (401) 822-6900 Licht Judicial Complex Providence/Bristol County 250 Benefit Street Providence, Rhode Island 029032719 (401) 458-3230 I, ___________________________________________, of ___________________________ _________________________________________, upon oath and say as follows: 1. That the Defendant has failed to plead or otherwise defend as provided by the rules of this court. 2. That the Defendant was not at the commencement of the above-entitled action, nor is now, in the "Military Service" of the United States as defined in the Servicemember's Civil Relief Act, 50 App. U.S.C. § 521, nor is the Defendant an American citizen serving with the forces of a United States ally or a reservist/draftee called to active duty. 3. That the Defendant is not an infant or incompetent. 4. That the Defendant presently resides at ________________________________________ ______________________________________________________________________________. Superior-49 (revised November 2014) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT (Complete sections five and six only if this cause seeks to recover a sum certain. Otherwise, you must assign the case for hearing on the Special Cause Calendar with notice to the Defendant to obtain a judgment of money damages) 5. That this cause was commenced to recover a sum certain of $_______________ plus interest from ________________ to ________________ in the amount of $_______________, totaling $_______________. 6. That the Defendant has no setoffs or counterclaims against this account and, in my opinion, there is no defense to this claim or cause of action. Rhode Island Bar Number: /s/ _________________________________________________ Attorney for the Plaintiff or the Plaintiff Date: Telephone Number: State of _______________________ County of _____________________ On this ________ day of ________________, 20____, before me, the undersigned notary public, personally appeared ____________________________________ personally known to the notary or proved to the notary through satisfactory evidence of identification, which was _____________________________________________, to be the person who signed the preceding or attached document in my presence, and who swore or affirmed to the notary that the contents of the document are truthful to the best of his or her knowledge. Notary Public: ____________________________________ My commission expires: ________________________ Notary identification number: _______________ Date of Entry of Default Clerk /s/ __________________________________________ Superior-49 (revised November 2014) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT CERTIFICATE OF SERVICE I hereby certify that, on the ______ day of _____________________, 20____: I filed and served this document through the electronic filing system on the following parties: ______________________________________________________________________. The document electronically filed and served is available for viewing and/or downloading from the Rhode Island Judiciary's Electronic Filing System. I served this document through the electronic filing system on the following parties: _____________________________________________________________________________. The document electronically served is available for viewing and/or downloading from the Rhode Island Judiciary's Electronic Filing System. I mailed or hand-delivered this document to the attorney for the opposing party and/or the opposing party if self-represented, whose name is __________________________________ at the following address _________________________________________________________. /s/ _________________________________ Name Superior-49 (revised November 2014) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com