Los Angeles local civil form — Request for Entry of Judgment, Judgment, and Notice of Entry of Judgment Labor Code Section 5806 (LASC LACIV 215)

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NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk’s File Stamp

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ATTORNEY FOR (Name): entered on your form, SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES please press the Clear COURTHOUSE ADDRESS: This Form button at the PLAINTIFF/PETITIONER: end of this form when finished. DEFENDANT/RESPONDENT:

CASE NUMBER:

REQUEST FOR ENTRY OF JUDGMENT, JUDGMENT, AND NOTICE OF ENTRY OF JUDGMENT – LABOR CODE SECTION 5806 AND ISSUANCE OF A WRIT OF EXECUTION AND/OR OTHER ENFORCEMENT

REQUEST FOR ENTRY OF JUDGMENT

The Clerk of the Court is requested to enter judgment in favor of: Plaintiff(s) Defendant(s)

Against Plaintiff(s) Defendant(s) , pursuant to the Labor Code section 5806 as follows:

a. Principal…….………………………………………………………………… $
b. Attorney Fees………………………………………………………………… $
c. Costs (including civil filing fee and administrative charge)……………… $
d. Amount of judgment requested ………………..……………………………$
e. Prejudgment interest of the annual rate for % ……………$
f. Total judgment requested ………………………………………………….. $
g. Plus interest after judgment at the legal rate.

A certified copy of the Order Approving Compromise & Release form of the Division of Workers Compensation is attached.

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

Dated: By:

Attorney for

SCLAC LACIV 215 Rev. 04/26 REQUEST FOR ENTRY OF JUDGMENT, JUDGMENT, Labor Code,§ § 5806, 5811 For Optional Use AND NOTICE OF ENTRY OF JUDGMENT - LABOR CODE SECTION 5806 Page 1 of 2

PLAINTIFF/PETITIONER (Name): CASE NUMBER

DEFENDANT/RESPONDENT (Name):

JUDGMENT AND NOTICE OF ENTRY OF JUDGMENT

Judgment entered in favor of: Plaintiff(s) Defendant(s)

Against Plaintiff(s) Defendant(s)

a. Principal…….………………………………………………………………… $
b. Attorney Fees………………………………………………………………… $
c. Costs granted by the Appeals Board . . . . . . . . . ………...……………… $
d. Amount of judgment requested ………………..……………………………$
e. Prejudgment interest of the annual rate for % ……………$
f. Total judgment requested ………………………………………………….. $
g. Plus interest after judgment at the legal rate.

Judgment entered on .

Dated: DAVID W. SLAYTON, Executive Officer/Clerk of Court

By: Deputy Clerk

CERTIFICATE OF MAILING

I, the below-named Executive Officer/Clerk of Court of the above-entitled court, do hereby certify that I am not a party to the cause herein, and that on this date I served the (begin underline) Request for Entry of Judgment, Judgment, an d Notice of Entry of Judgment – Laborupon each party or counsel named below by depositing in the United States mail at the courthouse in , California, one copy of the original filed/entered herein in a separate sealed envelope to each address as shown below with postage thereon fully prepaid.

DAVID W. SLAYTON, Executive Officer/Clerk of Court

By:
Deputy Clerk
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SCLAC LACIV 215 Rev. 04/26 REQUEST FOR ENTRY OF JUDGMENT, JUDGMENT, Labor Code,§ § 5806, 5811 For Optional Use AND NOTICE OF ENTRY OF JUDGMENT - LABOR CODE SECTION 5806 Page 2 of 2 To protect your privacy, please press the Clear This Form button, when you have finished printing this form.