COUNTY COURT – CIVIL DIVISION INDIAN RIVER COUNTY, FLORIDA SMALL CLAIMS AFFIDAVIT AS TO DEFENDANT’S DEFAULT IN STIPULATION OF PAYMENT The Plaintiff __________________________________ __________________________________ __________________________________ __________________________________ The Defendant ______________________________ ______________________________ ______________________________ ______________________________ The undersigned, being first duly sworn, deposes and says as follows: 1. That he/she (Plaintiff, Agent for Plaintiff, Attorney for Plaintiff) in Case No.________________ in county court of Indian River County, Florida where in _______________________________ is Plaintiff and ___________________________________________________________ _________________________________is Defendant. 2. That said Defendant has failed to make payment of money due said Plaintiff in the manner provided in the Stipulation herein before filed in this cause. 3. That the said Stipulation provided for payment for damages in the amount of $_________ and costs in the amount of $______________ for a total of $___________ and of that sum $______________ has been paid leaving a balance of $______________ now past due and unpaid. 4. That the Plaintiff moves the Court to issue a Final Judgment in the above referenced case ___ with ___ without an order requiring the defendant to complete a Fact Information Sheet. AND FURTHER THE UNDERSIGNED SAYETH NOT. _______________________________________ PLAINTIFF SUBSCRIBED AND SWORN TO BEFORE ME THIS ________ DAY OF ________________, 20____. _______________________________________ Deputy Clerk/Notary Public Notary Stamp small claim aff civ003 Revise: 04/11/2005 American LegalNet, Inc. www.FormsWorkflow.com