1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 IN THE CIRCUIT COURT OF THE STATE OF OREGON COUNTY OF DESCHUTES Plaintiff(s), vs. Defendant(s). ) ) ) ) ) ) ) ) ) ) Case No. DEFENDANT (S)222 AFFIDAVIT OR DECLARATION OF NON -COMPLIANCE (FED) I hereby swear or affirm that on , the Plaintiff(s) and Defendant(s) signed a Mediation Agreement which was filed with the Court and that Plaintiff(s) has not complied with the Mediation Agreement by failing to do the following:. I further swear or affirm that I have mailed a copy of this Affidavit or Declaration of Non-Compliance to Plaintiff(s) and have completed the Certificate of Mailing. I am requesting a general judgment in accordance with the proposed general judgment filed herewith. Page 1 226 DEFENDANT(S)222 AFFIDAVIT/DECLARATION OF NON-COMPLIANCE (FED) Rev 08/13 American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Signature Print name Address Phone SUBSCRIBED AND SWORN TO this day of , 20. TRIAL COURT ADMINISTRATOR By NOTICE TO PLAINTIFF(S) Information on how to request a hearing If you believe that you have complied with the mediated Agreement and that a general judgment should not be entered against you, then you must do ALL of the following immediately: 1. Fill out the attached Plaintiff(s)222 Request for Hearing to Contest the Affidavit of Non-Compliance. 2. Take it to the information counter at the Justice Building, 1100 NW Bond Street, Bend, Oregon, and give it to the court clerk at the counter. 3. Mail a copy of your Plaintiff(s)222 Request for Hearing to the Defendant(s). If you do not file a Plaintiff(s)222 Request for Hearing to Contest the Affidavit of Non-Compliance with the court clerk within four (4) days after you were served by mail with an affidavit of non-compliance, then the General Judgment attached hereto will be enforceable. If the four-day period ends on a weekend or holiday, then the period will be extended to the end of the next day that the courthouse is open. Page 2 226 DEFENDANT(S)222 AFFIDAVIT/DECLARATION OF NON-COMPLIANCE (FED) Rev 08/13 American LegalNet, Inc. www.FormsWorkFlow.com