SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE BANNING 311 E. Ramsey St ., Banning, CA 92220 MORENO VALLEY 13800 Heacock St., Ste. D201 , Moreno Valley, CA 92553 BLYTHE 265 N. Broadway, Blythe, CA 92225 MURRIETA 30755 - D Auld Road, Ste. 1226, Murrieta, CA 92563 CORONA 505 S. Buena Vista , Rm. 201, Corona, CA 92882 PALM SPRINGS 3255 E. Tahquitz Canyon Way, Palm Springs, CA 92262 HEMET 880 N. State St., Hemet, CA 92543 TEMECULA 41002 County Center Dr., Ste. 100, Temecula, CA 925 9 1 RI - SC00 1 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) FOR COURT USE ONLY TELEPHONE NO: FAX NO. (Optional): E - MAIL ADDRESS (Optional): ATTORNEY FOR (Name): PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT: CASE NUMBER: SMALL CLAIMS DECLARATION RE: DEFAULT IN PAYMENTS THE UNDERSIGNED JUDGMENT CREDITOR IN THE ABOVE ENTITLED ACTION DECLARES: 1. That judgment was entered against the following judgment debtor(s): 2. The total amount of $ has been paid on the judgment, and that the installment due on has not been paid. (DATE) Therefore, the judgment creditor requests that execution issue in the amount of $ . I declare under penalty of perjury under the laws of the State of California that the above statements are true and correct. Date: (TYPE OR PRINT NAME OF PARTY MAKING DECLARATION) (SIGNATURE OF JUDGMENT CREDITOR) Page 1 of 1 Approved for Optional Use Riverside Superior Court RI - SC001 [Rev. 06/13/17 ] SMALL CLAIMS DECLARATION RE : DEFAULT IN PAYMENTS Code of Civil Procedure 247 116.620 riverside.courts.ca.gov/localfrms/localfrms . shtml American LegalNet, Inc. www.FormsWorkFlow.com