T(s)/Debtor(s) My name is (Full name) I live in (Municipality & province) and I swear/affirm that the following is true: 1. In this action, I am the (Check one box only.) plaintiff/creditor. representative of the plaintiff(s)/creditor(s) (Name of plaintiff(s)/creditor(s)) 2. To date, I have received from the defendant(s)/debtor(s) $ , the last payment being made (Amount) on or about , 20 . 3. I make this affidavit in support of a request that: the clerk of the court issue a Default Jud.

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