IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY Small Claims Division - _____________________________________________________ (court’s address and phone number) ) ) ) ) ) ) ) ) Plaintiff v. Defendant(s) CASE No. _________________ REQUEST FOR DEFAULT JUDGMENT; DEFENDANT STATUS DECLARATION (NOTE: Complete this and attach a completed Judgment you propose) I, request default judgment against Name Other Party’s Name for the following : A total judgment award of $ , which total includes: 1. Money awarded in the amount of $ , 2. Prejudgment interest of $ , , if any, 3. Accrued arrearages of $ 4. Costs and service expenses of $ , 5. A prevailing party fee under ORS 20.190 of $ . I request judgment include postjudgment interest at a rate of % per based on (authority for interest) And, I request the following terms in addition to or in lieu of a money award: □ NONE, or I have attached a completed proposed small claims judgment for purposes of this request. 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 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 a respondent; (b) G is G is not G I am unable to determine whether this person is a person protected by the Servicemembers 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. Plaintiff’s Name (print) DATED: ___________________________ _____________________________________________ Authorized Signature Form 15.010.1c – REQUEST FOR DEFAULT JUDGMENT; DEFENDANT STATUS DECLARATION – UTCR 15.010(1)(c) (Revised 8-1-11) American LegalNet, Inc. www.FormsWorkFlow.com