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: 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 Plus interest after judgment at the legal rate. % ...............$ Total judgment requested ........................................................... $ 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 (Rev. 09/13) 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 American LegalNet, Inc. www.FormsWorkFlow.com 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 Plus interest after judgment at the legal rate. % ...............$ Total judgment requested ........................................................... $ Judgment entered on Dated: . SHERRI R. CARTER, 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. SHERRI R. CARTER, Executive Officer/Clerk By: Deputy Clerk Labor Code,§ § 5806, 5811 Page 2 of 2 LACIV 215 (Rev. 09/13) LASC Approved 09-08 REQUEST FOR ENTRY OF JUDGMENT, JUDGMENT, AND NOTICE OF ENTRY OF JUDGMENT LABOR CODE SECTION 5806 American LegalNet, Inc. www.FormsWorkFlow.com