Commonwealth of MassachusettsS U F F O L K , s s . TRIAL COURT OF THE COMMONWEALTHBOSTON MUNICIPAL COURT DEPARTMENT Civil No.Plaintiff(s) REQUEST FOR DEFAULT ( P u r s u a n t t o R u l e 5 5 ( a ) )Defendant(s)To the Clerk of the above-named Court:I , attorney for the above-named plaintiff(s), state that the complaint in which a judgment for affirmative relief issought against the defendant(s) herein, was filed on and the summons and a copy of the complaint have been served on the defendant(s) hereinon as appears from the officer's return; that the time within which the defendant(s) shallserve a responsive pleading or otherwise defend pursuant to Rule 12(a), has expired and the defendant(s) hereinhas/have failed to serve or file an answer or otherwise defend as to the complaint.Wherefore, the plaintiff(s)make(s) application that thedefendant(s) be defaulted. SIGNED UNDER THE PENALTIES OF PERJURY Signed Print or TypeAtty. for Plff Print or TypeAddress Tel. No. BBO No. PLAINTIFF'S REQUEST FOR JUDGMENT FOR RELIEF(Pursuant to Rule 55 (b)(1))The undersigned requests that judgment enter against the defendant(s) in the amount of $ together with interest in the sum of $ with costs and makeaffidavit that:1.The total amount due the plaintiff(s), exclusive of costs in the claim against the defendant(s), is$ . 2.That the defendant(s) is/are not an infant or incompetent person.3.That the defendant(s) is/are not in the military service of the United States or its Allies, as definedin the Servicemembers Civil Relief Act of 2003, as set forth in 50 U.S.C. App. 247247 501 et seq.,evidenced by the following facts: S u b s c r i b e d t h i s d a y o f , 2 0 u n d e r t h e p e n a l t i e s o f p e r j u r y .E x e c u t i o n r e q u e s t e d . P l a i n t i f f . BMC-CV-005 R E Q U E S T F O R D E F A U L T A N D D E F A U L T J U D G M E N T (Rev. 06/10 swf)D a t e d a t B o s t o n , M a s s a c h u s e t t s , t h i s d a y o f , 2 0 . American LegalNet, Inc. www.FormsWorkFlow.com