SC-5410VA, 05/18 Affidavit Based on Noncompliance Non-Eviction (Small Claims) 247799.24(3), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional materials. Page 1 of 2 Enter the name of the county 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. Enter the case number. Affidavit Based on Noncompliance Non - Eviction (Small Claims ) Case No. UNDER OATH I STATE: For 1, enter the date of the agreement which may be found on the Stipulation for Dismissal (Non - Eviction) (SC - 531 0 VA) , #2. Other Agreement. 1. The plaintiff(s) and the defendant(s) entered into a stipulation (a greement) for dismissal on [Date] . 2. The stipulation stated that if a party did not comply with the terms of the agreement, either party could a sk for a hearing to determine whether the dismissal should be vacated. For 3, explain how the terms of the agreement were violated. Describe which terms were not met. 3. The following terms of the agreement were not complied with : 4. I ask the court to schedule a hearing to determine whether the dismissal should be vacated. 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-5410VA, 05/18 Affidavit Based on Noncompliance Non-Eviction (Small Claims) 247799.24(3), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional materials. 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