San Luis Obispo — SC004

Source: https://www.slo.courts.ca.gov/system/files/forms-and-filings/sc004-default-mediated-agreement-no-judgment-2023.pdf

PARTY NAME AND ADDRESS FOR COURT USE ONLY

Plaintiff/Defendant

SUPERIOR COURT OF SAN LUIS OBISPO COUNTY SMALL CLAIMS DIVISION L San Luis Obispo Branch, 1035 Palm Street, Rm 385, San Luis Obispo, CA 93408 L Paso Robles Branch, 901 Park Street, Paso Robles, CA 93446

Plaintiff:

Defendant:

CASE NO:

DECLARATION OF DEFAULT IN PAYMENTS AND REQUEST FOR COURT HEARING (SMALL CLAIMS)

I, ___________________________________________________________ declare as follows:

DECLARANT NAME

I am the Plaintiff/Defendant in the within action. A Mediation Agreement was entered into on _______________________________ ,

whereby Plaintiff/Defendant __________________________________________________ was to make payments of $ __________per month

commencing on _____________, and said Plaintiff/Defendant has defaulted in making payments on my claim. To date I have received

$_. Other Terms:___________________________________________________________________________.

I am hereby requesting that the court set this matter on its earliest calendar date for entry of judgment.

On_______________________ , I mailed (by regular U.S. mail) a copy of this Declaration and Request for Hearing to Plaintiff/Defendant

at:___________________________________________________________________ _________________________ STREET ADDRESS CITY STATE ZIP

I declare under penalty of perjury under the laws of the State of California the foregoing is true and correct.

DATE ________________________

(SIGNATURE OF DECLARANT)

SC004 DECLARATION OF DEFAULT IN PAYMENTS AND CCP 116.620 Rev. 12/22/2023 Optional REQUEST FOR COURT HEARING (SMALL CLAIMS)