Approved, SCAO Original - Court 1st copy - Plaintiff Copies - All other parties STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT Court address DEFAULT REQUEST, AFFIDAVIT, ENTRY, AND JUDGMENT (SUM CERTAIN) CASE NO. Court telephone no. Plaintiff name, address, and telephone no. Defendant name, address, and telephone no. v Plaintiff's attorney, bar no., address, and telephone no. Defendant's attorney, bar no., address, and telephone no. USE NOTE: Plaintiff must complete the Request and Affidavit and the Default Judgment before filing with the court. REQUEST AND AFFIDAVIT 1. I request a default entry against for failure to appear. 2. The claim against the defaulted party is for a sum certain or for a sum, which by computation can be made certain. I request judgment for: Damages: $ Costs: $ Attorney fee/Other: $ Total judgment:$ . 3. The amount requested for damages is not greater than the amount stated in the complaint. 4. The defaulted party is not an infant or incompetent person. 5. It is unknown whether the defaulted party is in the military service. The defaulted party is not in the military service. The defaulted party is in the military but there has been notice of pendency of the action and adequate time and opportunity to appear and defend has been provided. Attached, as appropriate, is a waiver of rights and protections provided under the Servicemembers Civil Relief Act. Facts upon which this conclusion is based are: (specify) 6. This affidavit is made on my personal knowledge and, if sworn as a witness, I can testify competently to the facts in this affidavit. Applicant/Attorney signature Bar no. Subscribed and sworn to before me on My commission expires: Date Date , Signature: Deputy court clerk/Notary public County, Michigan. Notary public, State of Michigan, County of DEFAULT ENTRY The default of the party named above for failure to appear is entered. Date Court clerk DEFAULT JUDGMENT Damages: $ IT IS ORDERED this judgment is granted in favor of the plaintiff(s) as follows. Costs: $ Attorney fee/Other: $ Total judgment: $ *Attach bill of costs if statutory limit is exceeded. This judgment will earn interest at statutory rates, computed from the filing date of the complaint. Judgment interest accrued thus far is $ and is based on: If needed, attach separate sheet. the statutory rate of the statutory 6-month rate(s) of % from % from to to . . Court clerk/Judge Date The judgment has been entered and will be final unless, within 21 days of the default judgment date, a motion to set aside the default is filed. CERTIFICATE OF MAILING I certify that on this date I served a copy of this default entry and judgment on the parties or their attorneys by first-class mail addressed to their last-known addresses as defined by MCR 2.107(C)(3). Date MC 07a (12/12) Signature MCL 32.517, MCL 600.2441, MCL 600.5759, MCL 600.6013, MCR 2.603(B)(2), 50 USC 521 American LegalNet, Inc. www.FormsWorkFlow.com DEFAULT REQUEST, AFFIDAVIT, ENTRY, AND JUDGMENT (SUM CERTAIN)