DC-36 (revised June 2017) Page 1 of 3 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT APPLICATION TO CLERK FOR ENTRY OF DEFAULT Plaintiff Civil Action File Number Defendant Murray Judicial Complex 2 nd Division District Court 45 Washington Square Newport, Rhode Island 02840 - 2913 (401) 841 - 8350 Noel Judicial Complex 3 rd Division District Court 222 Quaker Lane Warwick, Rhode Island 02886 - 0107 ( 401) 822 - 6750 McGrath Judicial Complex 4 th Division District Court 4800 Tower Hill Road Wakefield, Rhode Island 02879 - 2239 (401) 782 - 4131 Garrahy Judicial Complex 6 th Division District Court One Dor rance Plaza Providence, Rhode Island 02903 - 2719 (401) 458 - 5400 The Plaintiff in the above-entitled action pursuant to Rule 55(a) of the Rhode Island District Court Rules of Civil Procedure hereby makes application to the Clerk for Entry of Default for the Plaintiff against the Defendant for failure of said Defendant to plead or otherwise defend. Said failure of the Defendant to plead or otherwise defend is set forth in the affidavit immediately following this application. /s/ Attorney for the Plaintiff or the Plaintiff Rhode Island Bar Number: Date: Telephone Number: American LegalNet, Inc. www.FormsWorkFlow.com DC-36 (revised June 2017) Page 2 of 3 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT AFFIDAVIT The undersigned, being duly sworn, upon oath deposes and says: 1. That I am the Plaintiff and have personal knowledge of the facts set forth in this affidavit; 2. That the Plaintiff on the day of , 20, filed in this action a Complaint against the Defendant; 3. duly served with a copy of the S 4. That more than days have elapsed since service of the Summons and Complaint; 5. and 6. That this Affidavit is executed by the affiant herein in accordance with Rule 55(a) of the Rhode Island District Court Rules of Civil Procedure for the purpose of enabling the Plaintiff to obtain an Entry of Default against the Defendant for failure to plead or otherwise defend as to the Signature of the Plaintiff State of County of On this day of , 20, before me, the undersigned notary public, personally appeared personally known to the notary or proved to the notary through satisfactory evidence of identification, which was , to be the person who signed above in my presence, and who swore or affirmed to the notary that the contents of the document are truthful to the best of his or her knowledge. Notary Public: My commission expires: Notary identification number: American LegalNet, Inc. www.FormsWorkFlow.com DC-36 (revised June 2017) Page 3 of 3 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT AFFIDAVIT AS TO MILITARY SERVICE AND COMPETENCY The undersigned, being duly sworn, upon information and belief deposes and say: That the Defendant is not an infant or an incompetent, and presently resides at in , Rhode Island; and [PLEASE CHECK THE APPLICABLE BOX] That the Defendant was not at the commencement of the above-entitled action, nor is now, in Civil Relief Act, 50 App. U.S.C. 247 521, nor is the Defendant an American citizen serving with the forces of a United States ally or a reservist/draftee called to active duty; or That despite exercising due diligence, the Plaintiff lacks sufficient information and has been Signature of the Plaintiff State of County of On this day of , 20, before me, the undersigned notary public, personally appeared personally known to the notary or proved to the notary through satisfactory evidence of identification, which was , to be the person who signed the preceding or attached document in my presence, and who swore or affirmed to the notary that the contents of the document are truthful to the best of his or her knowledge. Notary Public: My commission expires: Notary identification number: ENTRY OF DEFAULT It appearing that the Defendant in the above-entitled case has failed to plead or otherwise defend as provided by the Rhode Island District Court Rules of Civil Procedure, now therefore DEFAULT is hereby entered for the Plaintiff and against the Defendant. Date of Entry of De fault Clerk /s/ American LegalNet, Inc. www.FormsWorkFlow.com