PARTY INFORMATION (Name and address): TELEPHONE NO: FAX NO. (Optional) EMAIL ADDRESS (Optiona l): Plaintiff Defendant Other: FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ Small Claims Division Watsonville Branch 1 Second Street, Room 300 Watsonville, CA 95076 PLAINTIFF/PETITIONER : vs. DEFENDANT/RESPONDENT : DECLARATION AND ORDER RE: MEDIATED AGREEMENT DEFAULT CASE NUMBER: Form Adopted for OPT IONAL USE Superior Court of Santa Cruz County SUP SC 024 11 / 02 / 18 DECLARATION AND ORDER RE: MEDIATED AGREEMENT DEFAULT Page 1 of 2 SUP SC 024 I am the ( check one ) Plaintiff or Defendant in this case and I declare: 1. I am attaching a copy of the mediation agreement that we reached in this case on ( insert date ): . 2. The ( check one ) Plaintiff or Defendant has defaulted on this agreement. The payment or action due on (insert date): has not been received. 3. Prior payme nts totaling $ were received. 4. The outstanding balance or action is $. 5. Therefore I am requesting that Judgment be entered in this case against (insert name(s)): ; in the amount of $. 6. I am sending a copy of this request to all parties in this case by regular mail addressed as follows: American LegalNet, Inc. www.FormsWorkFlow.com PLAINTIFF/PETITIONER: DEFENDANT/RESPONDENT : CASE NUMBER : Form Adopted for OPT IONAL USE Superior Court of Santa Cruz County SUP SC 024 11 / 02 / 18 DECLARATION AND ORDER RE: MEDIATED AGREEMENT DEFAULT Page 2 of 2 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Print your name Sign here ( check one ) Plaintiff or Defendant ORDER IT IS ORDERED that the Clerk shall prepare a Notice of Entry of Judgment in the amount of $ principal and $ costs. Date: Jud ge of the Superior Court American LegalNet, Inc. www.FormsWorkFlow.com