IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY SMALL CLAIMS DEPARTMENT (Please type or print legibly) Plaintiff(s): 1.) _____________________________ CASE NUMBER: ______________ 2.) _____________________________ REQUEST FOR DEFAULT JUDGMENT; DEFENDANT STATUS AFFIDAVIT vs. Defendant(s): 1.) _____________________________ 2.) _____________________________ NOTE: Complete this and attach a completed judgment you propose. I, ______________________________________ request default judgment against ___________________________________________ defendant(s), for the following: A total judgment award of $__________________ which total includes: 1. Money awarded in the amount of $_______________, 2. Prejudgment interest of $_______________, 3. Accrued arrearages of $_______________, if any, 4. Costs and service expenses of $_______________, 5. A prevailing party fee under ORS 20.190 of: $ 85.00 , 6. The amount paid since filing the claim is $_______________. I request the judgment include post judgment interest at a rate of _____% per ________ based on:__________________________. (Note statutory interest is 9% per annum unless a contract/agreement differs.) And, I request the following terms in addition to or in lieu of a money award NONE, or _______________________________________________________________ In furtherance of this request, I state that: 1. The above-named defendant(s) was duly and regularly served with a copy of the claim and failed to pay the claim or demand a hearing or trial within 14 days: 2. The person against whom I seek a judgment by this request: a) is not one of the following defined by ORS 125.005 and protected by ORCP 69 B; a minor, incapacitated, a protected person or respondent; b)  is  is not  I am unable to determine whether this person is a person protected by the Service members Civil Relief Act (50 U.S.C. App 501 to 596). The facts that support this statement are: ___________________________________ _________________________________________________________________. I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. ____________________________ DATED: __________________ Plaintiff’s Name (print) _____________________________ Authorized Signature Public SmClaims Request Default Judgment Page 1 of 1 7/16/10 OJIN code: RQJD American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY SMALL CLAIMS DEPARTMENT (Please type or print legibly) Plaintiff(s): 1.) _____________________________ CASE NUMBER: ______________ 2.) _____________________________ LIMITED JUDGMENT GENERAL JUDGMENT vs. Defendant(s): 1.) _____________________________ 2.) _____________________________ I hereby give judgment in this case for the Judgment Creditor named in the money judgment/money award below and against the judgment debtor(s) named therin. In addition or in lieu of the money award below, this judgment established the following requirements: None OR _________________________________________________ _________________________________________________________________________ Based upon ____________________________________________________’s failure to appear for the scheduled Mediation Hearing (check box if applicable). MONEY JUDGMENT Judgment Creditor(s): __________________________________________________ Creditor’s Address: __________________________________________________ Judgment Debtor(s): __________________________________________________ Debtor’s Address: __________________________________________________ Judgment Amount: $_______________________ Prejudgment Interest: $_______________________ Costs and Service Fees: $ _______________________ Prevailing Party Fee: $85.00 Post Judgment Interest: __________% per annum _____________________ Date Public SmClaims Default Judgment ____________________________ Circuit Court Judge/Clerk Page 1 of 1 7/16/10 OJIN code: JGLN/JGLM or JGGL/JGGM American LegalNet, Inc. www.FormsWorkFlow.com