IN THE COUNTY COURT, FOURTEENTH JUDICIAL CIRCUIT IN AND FOR BAY COUNTY, FLORIDA SMALL CLAIMS DIVISION ____________________________ Plaintiff Case No: ________________ ____________________________ Address ____________________________ City, State and Zip Code -vs____________________________ Defendant ____________________________ Address ____________________________ City, State and Zip Code AFFIDAVIT OF NON-COMPLIANCE WITH STIPULATION AGREEMENT Before me, the undersigned authority, personally appeared __________________ _____________________, who being first duly sworn, deposes and says: The defendant _______________________________, has failed to comply with the Stipulation dated ________________, 20_____, in which said Defendant admitted a debt in the sum of $_______________ and agreed to pay Plaintiff, __________________ The amount of $_____________ monthly/weekly until paid in full. Defendant has defaulted in payments as of ________________, 20________ and owes Plaintiff $____________; and therefore, the Plaintiff request a Final Judgment be entered in the sum of $ _____________ together with costs in the amount of $________. ____________________________ Affiant SWORN TO AND SUBSCRIBED BEFORE ME THIS ________ day of ____________, 20______. _____________________________ Deputy Clerk or Notary Public Form D American LegalNet, Inc. www.FormsWorkFlow.com