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American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY Small Claims Department ) ) ) Case No: Plaintiff ) v. ) DECLARATION OF ) NONCOMPLIANCE AND ) REQUEST FOR JUDGMENT ) Defendant ) Attach a completed Small Claims General Judgment and Small Claims Agreement I, (name) , signed a Small Claims Agreement on (date) with . A copy of the agreement is attached. has not complied with (followed) the agreement. Explain I did not prevent the other party from complying with the agreement. I request judgment against (name) for $ , which includes 1. Money Award $ 2. Prejudgment Interest $ 3. Costs & Service Expenses $ 4. Attorney Fees $ 5. Prevailing Party Fee (listed at ORS 20.190) $ Plus Postjudgment 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, 4, and 5 at the rate set by ORS 82.010(2) Instead of or in addition to a money award, I request judgment for the following terms: On (date) , I mailed a copy of this request to the person I request judgment against at (address) I hereby declare that the above statements are true to the best of my knowledge and belief, and that I understand they are made for use as evidence in court and I am subject to penalty for perjury. Dated Signature Print Name Form 15.010.1c DECLARATION OF NONCOMPLIANCE AND REQUEST FOR JUDGMENT UTCR 15.010(1)(c) (Revised 8-1-12) Case No.