IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY SMALL CLAIMS DEPARTMENT Plaintiff vs. Case Number: REQUEST FOR JUDGMENT (NON-COMPLIANCE OF LANDLORDTENANT MEDIATION AGREEMENT) Defendant The parties entered into a Mediation Agreement filed on On in case number: . I (we) filed an Affidavit of Non-Compliance in that case. Pursuant to the terms of the Mediation Agreement, I (we) am now requesting that judgment be entered for the unpaid sum of . Additionally, I (we) am requesting costs; and $93.00 prevailing party fees. A copy of the Mediation Agreement and a copy of the Affidavit of Non-Compliance are attached. 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. ________________________________ Signature Name: Address: City: Phone: State: OR Zip Code: ________________________________ Date SmClaims Request Judgment Pursuant FED Mediation Agreement Page 1 of 2 7/15/11 American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR JACKSON COUNTY SMALL CLAIMS DEPARTMENT Plaintiff vs. Case Number: LIMITED GENERAL JUDGMENT (UPON AFFIDAVIT OF NON-COMPLIANCE ON LANDLORDTENANT MEDIATION AGREEMENT) Defendant Pursuant to the Mediation Agreement and Affidavit of Non-Compliance filed in case number: and upon filing of the Request for Judgment; judgment is hereby entered in favor of plaintiff(s) and against defendant(s). MONEY AWARD Creditor(s): Creditor(s): Address: City: Debtor(s): Debtor(s): Address: City: Judgment: Costs: Prevaling Party Fee: $93.00 % per annum simple. ________________________________ Circuit Court Judge Page 2 of 2 7/15/11 American LegalNet, Inc. www.FormsWorkFlow.com State: OR Zip Code: State: OR Zip Code: Post-Judgment Interest: 9 ________________________________ Date SmClaims Judgment Pursuant FED Mediation Agreement