PARTY NAME AND ADDRESS FOR COURT USE ONLY Plaintiff/Defendant SUPERIOR COURT OF SAN LUIS OBISPO COUNTY SMALL CLAIMS DIVISION San Luis Obispo Branch, 1035 Palm Street, Rm 385, San Luis Obispo, CA 93408 Grover Beach Branch, 214 South 16th Street, Grover Beach, CA 93433 Paso Robles Branch, 901 Park Street, Paso Robles, CA 93446 Plaintiff: Defendant: DECLARATION OF DEFAULT IN PAYMENTS AND REQUEST FOR COURT HEARING (SMALL CLAIMS) CASE NO: I, DECLARANT NAME declare as follows: , per month, I am the plaintiff/defendant in the within action. A Mediation Agreement was entered into on whereby plaintiff/defendant commencing To date I have received $ was to make payments of $ , and said Plaintiff/defendant has defaulted in making payments. on my claim. I am hereby requesting that the court set this matter on its earliest calendar for entry of judgment. On Hearing to plaintiff/defendant, at: , I mailed (by regular U.S. mail) a copy of this Declaration and Request for STREET ADDRESS CITY STATE ZIP I declare under penalty of perjury under the laws of the State of California the foregoing is true and correct. DATE (SIGNATURE OF DECLARANT) SC004 Rev. 08/01/2009 Optional DECLARATION OF DEFAULT IN PAYMENTS AND REQUEST FOR COURT HEARING (SMALL CLAIMS) CCP 116.620 American LegalNet, Inc. www.FormsWorkFlow.com