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Small Claims Judgment-Money Award Form. This is a Oregon form and can be use in Uniform Trial Court Statewide.
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Tags: Small Claims Judgment-Money Award, 15.010.1d, Oregon Statewide, Uniform Trial Court
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 JUDGMENT;
NONCOMPLIANCE DECLARATION
(NOTE: Complete this and attach a completed Judgment you propose)
I,
request 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 $
,
3. Accrued arrearages of $
, if any,
,
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: G NONE, or
I have attached a completed proposed small claims judgment for purposes of this request.
I, ___________________________________, hereby swear or affirm that on ____________________________
(date agreement signed)
____________________________________ and I signed a Mediation Agreement which has been entered
(Print other party’s name)
in this case and which contained the following terms. ________________________________________________
__________________________________________________________________________________________
_____________________________________ has not complied with the agreement by failing to do the following:
(print other party’s name)
__________________________________________________________________________________________
__________________________________________________________________________________________
I did not keep the other party from following the agreement. I certify that on
I mailed a copy
(date)
of this request to the party against whom I request judgment at
(address)
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 15.010.1d – REQUEST FOR JUDGMENT; NONCOMPLIANCE DECLARATION – UTCR 15.010(1)(d)
(Revised 8-1-11)
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