Party Name and Address FOR COURT USE ONLY Telephone No. Plaintiff/Defendant SUPERIOR COURT OF CALIFORNIA, COUNTY OF PLUMAS Main Courthouse: 520 Main Street, Quincy, CA 95971 Chester Branch: 222 First Avenue, Chester, CA 96020 Greenville Branch: 115 State Hwy 89, Greenville, CA 95947 Portola Branch: 600 S. Gulling Street, Portola, CA 96122 PLAINTIFF: CASE NUMBER: DEFENDANT: DECLARATION OF DEFAULT IN PAYMENTS AND REQUEST AND ORDER FOR ENTRY OF JUDGMENT (SMALL CLAIMS) declare as follows: I, I am the Plaintiff/Defendant in the above entitled action. A Mediation Agreement (attached hereto) was entered into on . Plaintiff/Defendant has defaulted in making payments as set forth in the agreement. To date . I have received $ . I am hereby requesting that the Court enter judgment in the remaining amount of $ On , I mailed (by regular U.S. Mail) a copy of this Declaration and Request for Entry of Judgment to Plaintiff/Defendant at . I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: Signature of Declarant GOOD CAUSE APPEARING, IT IS NOW ORDERED that Judgment be entered in the amount of $ and costs in the amount of $ . Dated: Judge of the Superior Court Declaration of Default in Payments and Request and Order for Entry of Judgment Small Claims PL – 003 CCP 116.620 American LegalNet, Inc. www.FormsWorkFlow.com