IN THE COUNTY COURT, SEVENTH JUDICIAL CIRCUIT IN AND FOR VOLUSIA COUNTY, FLORIDA

Case Number:

Division:

Plaintiff(s) -vs- AFFIDAVIT OF DEFAULT

IN STIPULATION

Defendant(s)

State of Florida County of Volusia

Before me this day personally appeared , Plaintiff in the above styled case, who duly sworn, deposes and says:

that , Defendant in the above styled case

has not made the payments according to the Stipulation entered into on (date) .

the Plaintiff is now entitled to an immediate Judgment against Defendant for

the total amount of $

Plaintiff has delivered a copy of this Affidavit to the Defendant by hand or mail this ______ day of __________________________, 20 _____.

Subscribed and sworn to (or affirmed) before me on

Signature of Plaintiff(s)by

(Name of affiant, deponent or other signer)

LAURA E. ROTH He/She is personally known to me or has presented CLERK OF COURT

(type of identification) as identification

By: Deputy Clerk

(Notary’s signature and seal)

CL-0963-1801

.