SC-5420VA, 05/18 Affidavit Based on Noncompliance for Money Judgment Non-Eviction (Small Claims) 247799.24(3), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Enter the name of the count in which this case was filed. STATE OF WISCONSIN CIRCUIT COURT, COUNTY Enter the Plaintiff( s ) name. Plaintiff(s): - vs - Defendant(s): Enter the Defendant( s ) name. Affidavit Based on Noncompliance For Money Judgment Non - Eviction (Small Claims) Case No. Enter the case number. For 1, enter the date of the agreement and amount that was to be paid which may be found on the Stipulation for Dismissal (Non - Eviction) (SC - 5310VA/VB), #1. Payment Agreement. UNDER OATH I STATE: 1. The parties entered into a stipulation (agreement) for dismissal on [Date] . The obligated party agreed to pay the prevailing party $ in full settlement of this case and the case was dismissed. For 2, enter the grace period (number of days) for payment and the amount the parties agreed could be entered as a judgment if the obligated party missed a payment. 2. The stipulation stated that if the obligated party missed any payment by more than days, the prevailing party could file this Affidavit of Nonc ompliance for Money Judgment (SC - 5420VA/VB) without notifying the obligated party, and ask the court to vacate the dismissal and enter judgment against the obligated party in the amount of $ , minus any payments made after the stipulation, plus statutory costs and disbursements as determined by the clerk of court. For 3, enter the date the payment was due. 3. The obligated party has missed a scheduled payment , which was due on [Date] , and any grace period for payment has expired. For 4, enter the amount of the stipulated judgment, the amount of the payments alre ady made, and the balance owed. 4. I ask the court to vacate the dis missal and enter judgment against the obligated party in the amount of $ , minus payments made of $ , for a total of $ , plus statutory costs and disbursements as determined by the clerk of court. STOP! Take this document to a Notary Public BEFORE you sign it. After you have been sworn by a Notary Public, sign and print your name and date the document in front of the Notary Public. Plaintiff(s)/Defendant(s) Print or Type Name Date State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: American LegalNet, Inc. www.FormsWorkFlow.com SC-5420VA, 05/18 Affidavit Based on Noncompliance for Money Judgment Non-Eviction (Small Claims) 247799.24(3), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 After you have been sworn by a Notary Public, sign and print your name and date the document in front of the Notary Public. Plaintiff(s)/Defendant(s) Print or Type Name Date State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: American LegalNet, Inc. www.FormsWorkFlow.com