IN THE COUNTY COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA

DIVISION CIVIL CASE NUMBER: 05 - - - -XXXX-XX

CLOCK IN ________________________________________,

Plaintiff

________________________________________, Defendant

AFFIDAVIT AS TO DEFENDANT'S DEFAULT IN STIPULATION OF PAYMENT

STATE OF FLORIDA COUNTY OF BREVARD

The undersigned, being first duly sworn, deposes and says as follows:

1. That he she is Plaintiff Agent for Plaintiff Attorney for Plaintiff in the abovestyled case.

2. That the above named Defendant(s) has (have) failed to make payment of money due saidPlaintiff(s) in the manner provided in the Stipulation hereinbefore filed in this cause.

3. That the said Stipulation provided for the payment of damages in the amount of$_______________ and costs in the amount of $_______________ for a total of $_______________, and of that sum $______________ has been paid leaving a balance of $_______________ now past due and unpaid.

4. That the Plaintiff(s) moves (s) the Court to render judgment in the above referenced case.

And further the undersigned saith not.

SWORN TO AND SUBSCRIBED TO ___________________________________ BEFORE ME THIS _______ DAY OF Plaintiff/Plaintiff's Agent/Plaintiff's Attorney _______________________, _______.

_______________________________ Notary Public/Deputy Clerk

Law 111 / Rev. 08-06-2015 1