IN THE COUNTY COURT, FOURTEENTH JUDICIAL CIRCUIT, IN AND FOR BAY COUNTY, FLORIDA ________________________________ Landlord ________________________________ Address ________________________________ City, State, and Zip Code -vs_________________________________ Tenant _________________________________ Address _________________________________ City, State, and Zip Code AFFIDAVIT ON NON-COMPLIANCE WITH STIPULATION AGREEMENT Before me, the undersigned authority, personally appeared _______________________________, and says: (Landlord) The tenant __________________________________ has failed to comply with the Stipulation attached. Said Tenant failed to do the following: _____ Pay according to paragraph #1 of the Stipulation. The Tenant owes $_______ in back rent/fees and $_______ in court costs. _____ Vacate the premises according to paragraph #3. Pursuant to the terms of paragraph #2 and/or paragraph #3 of the Stipulation agreement, the Landlord is entitled to judgment for possession and/or the amount of back rent and costs stated in the Stipulation with no further notice to Tenant. ________________________________ Affiant (Landlord) SWORN TO AND SUBSCRIBED BEFORE ME THIS _______day of ___________, 20____. ________________________________________ Deputy Clerk or Notary Public Case no. __________________ American LegalNet, Inc. www.FormsWorkFlow.com