COURT COUNTY OF ...................................................... : : : -againstPlaintiff(s) : : : : Defendant(s) : ...................................................... : Amount claimed in Complaint/Notice Interest SUBTOTAL Costs, Fees and Disbursements for: Costs by Statute - CPLR Article 82 Service of Summons and - CPLR � � 8301(d) and 8011(h) Affidavits - CPLR � 8009 Transcripts and Docketing - CPLR � 8021 Clerk's Fees for Entering Judgment - CPLR �� 8301(a)(7) and 8016(a)(2) Postage - CPLR � 8301(a)(12) Sheriff s Fees on Execution - CPLR ��� 8301(a)(8) and 8011(b), (c) and (d) and 8012 Satisfaction Piece - CPLR �� 5021 (a) and 8021 Taxing Costs CPLR � 8401 Index Number - CPLR � 8018 SUBTOTAL * Index No. STATEMENT FOR JUDGMENT (Default Judgment based upon Non-Appearance of Natural Person in Action based upon Non-Payment of Contractual Obligation) $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL Attorney's Affirmation STATE OF NEW YORK, COUNTY OF ss.: $ The undersigned, an attorney duly admitted to practice law in the courts of the State of New York, hereby affirms the following under penalty of perjury: I am** and as such, am fully familiar with the facts and circumstances of the above captioned action; that the foregoing costs are correct and were necessarily incurred in this action and are reasonable in amount; and that the services for which fees have been charged were actually and necessarily performed and are reasonable in amount. Dated: (Affirming attorney must sign above and type name below) Costs are taxed in the amount of and included in the judgment. Date: Clerk of the Court * ** Insert any other costs, fees or disbursements. Insert attorney of record information. 2003 � American LegalNet, Inc. www.USCourtForms.com JUDGMENT entered on The summons and in this action having been served upon the defendant(s) herein by (insert method of service) and the time for said defendant(s) to answer or otherwise appear having expired, and said defendant(s) not having answered or appeared; Now, on motion of attorney(s) for the plaintiff(s) herein, it is ADJUDGED, that the delivery of the possession of the property described in the petition be awarded to the petitioner/landlord with costs of this proceeding; and it is further ADJUDGED, that plaintiff(s) residing at recover of defendant(s) residing at the sum of $ which is the amount claimed, together with interest thereon in the sum of $ and $ costs and disbursements of this proceeding, amounting in all to the sum of $ the plaintiff have execution therefore. Dated: Enter, and that Justice Judgment entered in accordance with the foregoing. Dated: Clerk 2003 � American LegalNet, Inc. www.USCourtForms.com