NAME, ADDRESS, AND TELEPHONE NUMBER OF PARTY: Reserved for Clerk's File Stamp SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES SMALL CLAIMS COURTHOUSE ADDRESS: PLAINTIFF: DEFENDANT: DECLARATION OF JUDGMENT DEBTOR REGARDING SATISFACTION OF JUDGMENT CASE NUMBER: 1. I am the judgment debtor in this case. 2. Judgment was entered against me on ____________________________. 3. I have satisfied (paid) the judgment, as follows: Fully, including accrued interest, costs and administrative fees, if applicable. Partially in the amount of $__________. The judgment creditor refuses to accept any more payments. 4. I have requested that the judgment creditor file an acknowledgement of satisfaction of judgment. I made my request orally in writing on (date) ___________. As of the date of this declaration, the judgment creditor has failed or refused to comply with my request. I have been unable to contact the judgment creditor because his/her present address is unknown. 5. The following document(s), which constitutes evidence of full partial payment of the judgment is attached: Cancelled check money order written by me after judgment and made payable to, and endorsed by, the judgment creditor. Cash, receipt for the amount paid, signed by the judgment creditor. Other: _____________________________________________________________________. I declare under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct. DATE TYPE OR PRINT JUDGMENT DEBTOR'S NAME SIGNATURE OF JUDGMENT DEBTOR NOTE: THIS DOCUMENT IS NOT INTENDED FOR USE BY THE COUNTY RECORDER'S OFFICE. CLERK'S NOTATION OF ENTRY OF SATISFACTION Satisfaction of judgment entered in register of action pursuant to Code Civ. Proc., § 116.850, subdivision (c) as follows: Full Satisfaction. Partial Satisfaction in the amount of $____________________. Clerk's Certificate of Satisfaction of Judgment (LACIV 040) issued. SHERRI R. CARTER, Executive Officer/Clerk Date: By: , Deputy SCLA 003 (Rev. 12/14) LASC Approved 12/08 For Optional Use DECLARATION OF JUDGMENT DEBTOR REGARDING SATISFACTION OF JUDGMENT Code Civ. Proc., § 116.850(c) American LegalNet, Inc. www.FormsWorkFlow.com