FOR COURT USE ONLY NAME AND ADDRESS: TELEPHONE NO: NAME OF COURT: STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: Stanislaus County Superior Court City Towers Building 801 10th Street, 4th Floor 801 10th Street, 4th Floor Modesto, CA 95354 Small Claims Division PLAINTIFF: VS. DEFENDANT: AFFIDAVIT OF DEFAULT OF INSTALLMENT PAYMENTS Small Claims CASE NUMBER 1. I am the judgment Creditor in this case and I declare as follows: 2. Judgment was entered against ___________________________________________________(judgment debtor(s)). 3. Judgment was entered on ___________________ (date) for the total amount of $__________________________. 4. The Court ordered the judgment be paid in installments as follows: $________________ per month commencing on _____________________. 5. The debtor has not paid the sum of $_________________________due on ___________________ nor any payment thereafter. 6. Judgment Creditor requests that execution of Judgment be issued. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on: _______________ at ________________, California. (TYPE OR PRINT NAME) (SIGNATURE) IT IS SO ORDERED: DATE: ____________________________________ Judge of the Superior Court SC 003 OPTIONAL FORM AFFIDAVIT OF DEFAULT OF INSTALLMENT PAYMENTS (REV 1/11) American LegalNet, Inc. www.FormsWorkFlow.com