IN THE CIRCUIT COURT FOR THE STATE OF OREGON FOR THE COUNTY OF LINN SMALL CLAIMS DEPARTMENT ___________________________________________________ ___________________________________________________ Plaintiff, vs. ___________________________________________________ ___________________________________________________ Defendant. ) ) ) ) ) ) ) CASE NO: ____________________________ DECLARATION OF NON-COMPLIANCE I ______________________________________________ hereby declare that on ___________________, 20_____, _________________________________________________________ and I signed a mediation agreement and _________________________________________________________ has failed to comply. $___________________________ is the total amount to be paid as per the mediation agreement. At this time $____________________ has been paid and upon entry of judgment, a partial satisfaction may be entered in that amount. There is an unpaid balance of $__________________________. Dated: ______________________ ___________________________________________________ (your signature) ___________________________________________________ (address) ___________________________________________________ City State Zip Phone Number Attach Completed Small Claims General Judgment Form __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ NOTICE OF MAILING A copy of the Declaration has been mailed by the Court to the other party at their last known address. The other party has 10 days to respond and can request a hearing before the judgment is entered. DATE MAILED by Court: _____________________ to ____________________________________________________. ________________________________________ Court Clerk Rev 11/12 American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT FOR THE STATE OF OREGON FOR THE COUNTY OF LINN SMALL CLAIMS DEPARTMENT ___________________________________________________ ) ) ___________________________________________________ ) Plaintiff, ) ) vs. ) ___________________________________________________ ) ) ___________________________________________________ ) Defendant. ) ORDER IT IS HEREBY ORDERED that the previously entered Judgment of Dismissal from the mediation agreement is set aside. It is further ordered that Judgment shall be entered in the amount of $________________________ in favor of _______________________________________ and against _______________________________________________. CASE NO: ____________________________ ORDER SETTING ASIDE DISMISSAL AND GENERAL JUDGMENT MONEY AWARD Judgment Creditor: (name, address, phone number) Judgment Creditor's lawyer (name, address, phone number) Judgment Debtor(s) information Debtor 1 Name Address Year of Birth SSN (last 4 digits) or full Tax ID if known Driver License # (last 4 digits) & State if known *Additional information attached, titled "Additional Judgment Debtors" if more than two debtors Debtor 2 No person or public body other than Judgment Creditor and Judgment Creditor's lawyer is entitled to any part of this money award except: The total amount awarded by this judgment is $ 1. Money Award $ 3. Costs & Service Expenses $ , which includes: 2. Prejudgment Interest $ 4. Prevailing Party Fee (listed at ORS 20.190) $100.00 Plus Post judgment interest on the amount in sections 1 and 2 at the rate set by ORS 82.010(2) (or ______% by agreement of the parties), and in sections 3 and 4 at the rate set by ORS 82.010(2) **Date and signature to be completed by court personnel if judgment approved. __________________________ Date _____________________________________________ Circuit Court Judge _____________________________________________ Print Name American LegalNet, Inc. www.FormsWorkFlow.com