Civil Court of the City of New York Index No. COUNTY OF Part STIPULATION OF SETTLEMENT and AFFIDAVIT UPON DEFAULT Claimant(s), Plaintiff(s), -aga ins t- Defendant(s). STIPULATION OF SETTLEMENT It is hereby agreed by and between the parties that this claim is settle d for the sum of $ , to be (Amount) , on or before to at:paid by (Debtor) (Date) (Creditor) or as follows: (Address) Upon such payment all parties shall be released from liability to each o ther concerning the matters in this dispute. In the event Debtor fails to make payment as agreed to above, Creditor, upon completing the Affidavit below setting forth such default, shall be entitled to: (SELECT ONE OPTION) a) enter Judgment, without further notice to the Debtor, for the amount (originally sued for/agreed to above) less any payments made, together with interest and disbursements . (Cross out inapplicable choice) b) restore the case to the calendar for trial. Signature Date Signature Date Signature Date Signature Date AFFIDAVIT UPON DEFAULT OF STIPULATION State of New York, County of SS: , being duly sworn, deposes and says: (Creditor) This case was settled as indicated above. The Debtor has failed to compl y with the terms of the settlement. I, (Specify your request) Sworn to before me this day of 20 (Notary Public or Court Employee and Title) Signature of Deponent CIV-GP-31-i (Revised 1/03) American LegalNet, Inc. www.USCourtForms.com