PARTY NAME AND ADDRESS 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: Defendent: DECLARATION OF DEFAULT IN PAYMENTS (SMALL CLAIMS) CASE NO: I, DECLARANT NAME declare as follows: , ; JUDGMENT DEBTOR NAME I am the plaintiff/defendant in the within action. A judgment was entered into on For $ against the court ordered the judgment to be paid in installments of $ per month, commencing , and said plaintiff/defendant has defaulted in making payments. To date I have received $ The installment due on Therefore, I request that execution issue. On Issue to plaintiff/defendant, at: , I mailed (by regular U.S. mail) a copy of this Declaration and Request that Execution STREET ADDRESS on my claim. has not been paid. 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 SC002 Rev. 08/01/2009 Optional DECLARATION OF DEFAULT IN PAYMENTS (SMALL CLAIMS) CCP 116.620 American LegalNet, Inc. www.FormsWorkFlow.com