IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY SMALL CLAIMS DEPARTMENT Case Number: Plaintiff AFFIDAVIT OF NON-COMPLIANCE and Defendant I, hereby swear or affirm that on Name Date agreement signed , and I signed a Mediation Agreement, and that party has failed to comply Other party's name by failing to do the following: At this time a total of has been paid and there is an unpaid balance of ________________________________ Date SUBSCRIBED AND SWORN TO BEFORE ME ON County, Oregon. ________________________________ Signature ________________________________, in Jackson Date Trial Court Administrator By: ___________________________________ Court Clerk/Notary Public My commission expires:________________ SmClaims Affidavit Judgment Noncompliance AFNC 09/08 American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY SMALL CLAIMS DEPARTMENT Case Number: Plaintiff GENERAL JUDGMENT and Defendant Based on the foregoing affidavit and for good cause appearing, IT IS HEREBY ORDERED AND ADJUDGED that a judgment shall be entered for and against , in the amounts set out in the Money Award below: MONEY AWARD Judgment Creditor: Judgment Debtor: Judgment Amount: Pre Judgment Interest Amount: Costs and Service Fees: Prevailing Party Fee: Post Judgment Interest: 9% ________________________________ Date ________________________________ Circuit Court Judge Print Form Affidavit Judgment NonCompliance JGGM 09/08 American LegalNet, Inc. www.FormsWorkFlow.com