NAME, ADDRESS & TELEPHONE NUMBER OF JUDGMENT DEBTOR FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF MARIN 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: DECLARATION OF JUDGMENT DEBTOR REGARDING SATISFACTION OF JUDGMENT Code of Civil Procedure §116.850(C) 1. I am the judgment debtor in this case. 2. Judgment was entered against me on _____/_____/_____ in the amount of $ ______________ including costs. 3. I have satisfied (paid) the judgment, as follows: Fully, including accrued interest and costs. Partially in the amount of $ ______________. judgment creditor refuses to accept any more payments. The 4. have requested that the judgment creditor file an acknowledgment of satisfaction of judgment. I made I my request orally writing on _____/_____/_____. As of the date of this declaration, the judgment in credit 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. Case receipt for the amount paid, signed by the judgment creditor. 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 CLERK'S NOTATION OF ENTRY OF SATISFACTION Full satisfaction. Partial satisfaction in the amount of $ ______________. JAMES M. KIM Court Executive Officer Date: _____/_____/_____ By: DEPUTY SC012 DECLARATION OF JUDGMENT DEBTOR RE SATISFACTION OF JUDGMENT Rev. 8/12/15 American LegalNet, Inc. www.FormsWorkFlow.com