IN THE COUNTY COURT OF POLK COUNTY, FLORIDA

CIVIL DIVISION

CASE NO. ________________________

Plaintiff ,

vs.

Defendant .

______________________________________/

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____.

                                                                                                                                _________________________________

                                                                                                                                Plaintiff

Sworn to and subscribed before me this _____ day of _________________, 19____.

                                                                                                                                _________________________________

                                                                                                                                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 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)