IN THE COUNTY COURT OF POLK COUNTY, FLORIDA
CASE NO. ________________________
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 _________________, 19___. The defendant failed to pay as agreed, the last payment having been made on _______________, 19___. Accounting is as follows:
Principal amount, interest and attorney fees $_______________
Plus Court Costs + $_______________
Plus interest to date at ___% + $_______________
Less total payments received - $_______________
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 ________________, 19____.
Sworn to and subscribed before me this _____ day of _________________, 19____.
Deputy Clerk/Notary Public
My Commission Expires:
O R D E R
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 costs of $_________.
DONE AND ORDERED this _____ day of ________________, 19____.
JUDGE OF THE COUNTY COURT
Copy to above parties.
Rev. 9/91 C:\civil\forms\82.doc (01/97)