Joseph E. Smith Clerk of the Circuit Court St. Lucie County, Florida County Civil division 250 N.W. Country Club Drive Port Saint Lucie, Florida 34986 (772) 785-5880 In the County Court, Nineteenth Judicial Circuit, in and for County of St. Lucie, State of Florida ­ Civil Division Case No: PLAINTIFF, VS DEFENDANT. ___________________________/ AFFIDAVIT OF NON-PAYMENT THE UNDERSIGNED, being first duly sworn, deposes and says as follows: 1. That he/she is the (Plaintiff) (Plaintiff's Agent) in the above styled case wherein ___________________, is/are Plaintiff(s) and ____________________ is/are Defendant(s). 2. That said Defendant has failed to make payment of money due said Plaintiff in the manner provided in the stipulation herein filed in this cause. 3. That the money stated in said stipulation to be due said Plaintiff(s) from said Defendant(s) is $____________ damages, plus $_____________ for interest and $_______________ for court costs are now past due and wholly unpaid. And further affiant sayeth not. _____________________________ PLAINTIFF SUBSCRIBED AND SWORN to before me this _____ day of ____________________, 20____, by _________________________________________. ____________________________ NOTARY PUBLIC PERSONALLY KNOWN _____ OR PRODUCED IDENTIFICATION ______ IDENTIFICATION PRODUCED _____________________________________ American LegalNet, Inc. www.FormsWorkFlow.com