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IN THE COUNTY COURT OF POLK COUNTY, FLORIDA CIVIL DIVISION CASE NO. ________________________ Plaintiff (s), vs. Defendant (s). ______________________________________/ AFFIDAVIT OF DEFAULT IN PAYMENT STATE OF FLORIDA COUNTY OF POLK I, _______________________________ , after being placed under oath, do swear or affirm that the defendant agreed to make payments to the plaintiff in the amount of $________ weekly / monthly beginning on _________________, _____. The defendant failed to pay as agreed, the last payment having been made on _______________, _____. Accounting is as follows: Principal amount stated on judgment Plus attorney fees stated on judgment Plus court costs stated on judgment Plus interest stated on judgment Plus interest from date of judgment at ___% Less total payments received since judgment TOTAL AMOUNT DUE TO DATE + + + + - $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Plaintiff requests that the Court enter Final Judgment for the amount due, or in the event that a Judgment has been entered with Stay of Execution, that the Court remove the Stay of Execution. Dated this _____ day of ________________, ______. _____________________________________ Plaintiff Sworn to and subscribed before me this _____ day of _________________, ______. Personally Known STACY M. BUTTERFIELD Clerk of the Circuit Court Produced Identification Type of Identification presented: _______________________________ ORDER By___________________________________ Deputy Clerk/Notary Public My Commission Expires: The above captioned matter having come before the Court, and the Court having reviewed the Affidavit, it is ORDERED AND ADJUDGED that JUDGMENT BE ENTERED / STAY OF EXECUTION BE REMOVED for the balance owing of $____________ plus $__________ interest plus $__________ costs; and $_________ interest that does not accrue interest. DONE AND ORDERED this _____ day of ________________, ____. _____________________________________________ JUDGE OF THE COUNTY COURT Copy to above parties. American LegalNet, Inc. www.FormsWorkflow.com