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Here is the text we could read:

ATTORNEY OR PARTY WITHOUT ATTORNEY:

STATE BAR NO.:

FOR COURT USE ONLY

CIV-105

STATE:

FAX NO.:

ZIP CODE:

NAME:

FIRM NAME:

STREET ADDRESS:

CITY:

TELEPHONE NO.:

E-MAIL ADDRESS:

ATTORNEY FOR (name):

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

Plaintiff/Petitioner:

Defendant/Respondent:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:

1.  On the complaint or cross-complaint filed 

a. on (date):  

by (name):  

b.

c.

d.

Enter default of defendant (names):

REQUEST FOR (Application)

Entry of Default 

Judgment

CASE NUMBER:

For use only in actions under the Fair Debt Buying Practices Act (Civ. Code, § 1788.50 et seq.)

I request a judgment under Civil Code section 1788.60 and Code of Civil Procedure section 585 against defendant 
(names):

(Testimony may be required. Check with the clerk regarding whether a hearing date is needed.)

e.

Default was previously entered on (date):

2. 

Amount

Judgment to be entered.
a. 
Demand of complaint*
b. 
Interest  
c. 
Costs (see page 3)
d. 
Attorney fees
e.
TOTALS  
(* Must be established by business records, authenticated through a sworn declaration, submitted with this application. (Civ. 
Code, §§ 1788.58(a)(4), 1788.60(a).))

Credits acknowledged

Balance

$
$
$
$
$

$
$
$
$
$

$
$
$
$
$

3.  This action is not barred by the applicable statute of limitations (Civ. Code, § 1788.56).

4.  Requirements for the complaint. 

a.

The complaint alleges ALL of the following (Civ. Code, §§ 1788.58, 1788.60):

(1) That the plaintiff is a debt buyer;

derived; 

(2) A short, plain statement regarding the nature of the underlying debt and the consumer transaction from which it is 

(3) That the plaintiff is EITHER the sole owner of the debt OR has the authority to assert the rights of all owners of the debt;

(4)  The debt balance at charge-off and an explanation of the amount and nature of, and reason for, all post-charge-off 

interest and fees, if any, imposed by the charge-off creditor or any subsequent purchasers of the debt;

(5) The date of the default OR the date of the last payment; 

(6) The name and address of the charge-off creditor at the time of charge-off in sufficient form so as to reasonably identify 

the charge-off creditor, and the charge-off creditor's account number associated with the debt;

Form Adopted for Mandatory Use  
Judicial Council of California  
CIV-105 [Rev. January 1, 2023]

REQUEST FOR ENTRY OF DEFAULT 
(Fair Debt Buying Practices Act)

Page 1 of 3

Code of Civil Procedure, § 585; 
Civil Code, § 1788.60 
www.courts.ca.gov

Plaintiff/Petitioner: 

Defendant/Respondent:

CASE NUMBER:

CIV-105

4. 

a.

(7)

The name and last known address of the debtor as they appeared in the charge-off creditor's records prior to the sale of 
the debt; 

(8)

The names and addresses of all persons or entities that purchased the debt after charge-off, including the plaintiff debt 
buyer, in sufficient form so as to reasonably identify each such purchaser; and

(9)

That the plaintiff has complied with Civil Code section 1788.52.

b.  A copy of the contract or other document described in Civil Code section 1788.52(b) is attached to the complaint.

5.

Documentation requirements for default judgment. ALL of the following documents are submitted with this request for default 
judgment (Civ. Code, § 1788.60(a)–(c)):

a. A copy of the contract or other document evidencing the debtor's agreement to the debt, authenticated through a sworn 

declaration. See Civil Code section 1788.52(b) regarding documentation, including for revolving credit accounts.

b. Business records, authenticated through a sworn declaration, to establish:

(1) That the plaintiff is EITHER the sole owner of the debt OR has the authority to assert the rights of all owners of the debt;

(2) The debt balance at charge-off, and an explanation of the amount and nature of, and reason for, all post-charge-off 

interest and fees, if any, imposed by the charge-off creditor or any subsequent purchasers of the debt;

(3) The date of the default OR the date of the last payment;

(4) The name and address of the charge-off creditor at the time of charge-off in sufficient form so as to reasonably identify 

the charge-off creditor, and the charge-off creditor's account number associated with the debt;

(5) The name and last known address of the debtor as they appeared in the charge-off creditor's records prior to the sale of 

the debt; and

(6) The names and addresses of all persons or entities that purchased the debt after charge-off, including the plaintiff debt 

buyer, in sufficient form so as to reasonably identify each such purchaser.

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF PLAINTIFF OR ATTORNEY FOR PLAINTIFF)

FOR COURT 
USE ONLY

(1)
(2)

Default entered as requested on
Default NOT entered as requested

(date):

(state reason):

Clerk, by

, Deputy

6. Legal document assistant or unlawful detainer assistant (Bus. & Prof. Code, § 6400 et seq.). A legal document assistant or      

unlawful detainer assistant
received any help or advice for pay from a legal document assistant or unlawful detainer assistant, state:
a.

Assistant's name:

did not  

Telephone no.:

did

c.

for compensation give advice or assistance with this form. If declarant has 

b.

Street address, city, and zip code:

d.

e.
f.

County of registration: 

Registration no.:
Expires on (date):

7.

Declaration under Code Civ. Proc., § 585.5 (for entry of default under Code Civ. Proc., § 585(a)). This action

is not

on a contract or installment sale for goods or services subject to Civ. Code, § 1801 et seq. (Unruh Act). 

is not

on a conditional sales contract subject to Civ. Code, § 2981 et seq. (Rees-Levering Motor Vehicle Sales 
and Finance Act).

is not

on an obligation for goods, services, loans, or extensions of credit subject to Code Civ. Proc., § 395(b).

a. 

b. 

c. 

is

is

is

CIV-105 [Rev. January 1, 2023]

Page 2 of 3

REQUEST FOR ENTRY OF DEFAULT 
(Fair Debt Buying Practices Act) 

Plaintiff/Petitioner:

Defendant/Respondent:

CASE NUMBER:

CIV-105

8. Declaration of mailing (Code Civ. Proc., § 587). A copy of this Request for Entry of Default was

not mailed to the following defendants, whose addresses are unknown to plaintiff or plaintiff's attorney (names):

mailed first-class, postage prepaid, in a sealed envelope addressed to each defendant's attorney of record or, if none, 
to each defendant's last known address as follows: 

(1) Mailed on (date):

(2)

To (specify names and addresses shown on the envelopes):

I declare under penalty of perjury under the laws of the State of California that the foregoing items 6, 7, and 8 are true and correct.

(TYPE OR PRINT NAME)

(SIGNATURE OF DECLARANT)

9. Declaration of nonmilitary status (required for a judgment). 

No defendant/respondent named in item 1c is in the military service of the United States as defined by either the Servicemembers 
Civil Relief Act (see 50 U.S.C. § 3911(2)) or California Military and Veterans Code sections 400 and 402(f).

I know that no defendant/respondent named in item 1c is in the U.S. military service because (check all that apply):

the search results that I received from https://scra.dmdc.osd.mil/ say the defendant/respondent is not in the U.S. military 
service.
I am in regular communication with the defendant/respondent and know that they are not in the U.S. military service.
I recently contacted the defendant/respondent, and they told me that they are not in the U.S. military service.
I know that the defendant/respondent was discharged from U.S. military service on or about (date):
the defendant/respondent is not eligible to serve in the U.S. military because they are:

incarcerated

a business entity

other (specify):

•   U.S. military status can be checked online at https://scra.dmdc.osd.mil/. 
•   If the defendant/respondent is in the military service, or their military status is unknown, the defendant/respondent 
    is entitled to certain rights and protections under federal and state law before a default judgment can be entered.  
•   For more information, see https://selfhelp.courts.ca.gov/military-defaults.

Note 

10. Memorandum of costs (required if money judgment requested). Costs and disbursements are as follows (Code Civ. Proc., 

 § 1033.5):

Clerk's filing fees  ..............................................  $

Process server's fees ........................................  $

Other (specify):

$

$

TOTAL  ............................................................. $

Costs and disbursements are waived.

I am the attorney, agent, or party who claims these costs. To the best of my knowledge and belief this memorandum of costs 
is correct and these costs were necessarily incurred in this case.

I declare under penalty of perjury under the laws of the State of California that the foregoing items 9 and 10 are true and correct.

(TYPE OR PRINT NAME)

(SIGNATURE OF DECLARANT)

CIV-105 [Rev. January 1, 2023]

Page 3 of 3

REQUEST FOR ENTRY OF DEFAULT 
(Fair Debt Buying Practices Act) 

a. 

b. 

Date:

a. 

b. 
c. 
d. 

e. 

f.

a. 

b. 

c. 

d. 

e. 

f. 

g. 

Date:

Request for Entry of Default (Fair Debt Buying Practices Act)

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 3
Fields(s): 95
Average fields per page: 31
Reading Level: Grade 8
LIST Grouping(s): MO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

v_page_p_header_info_state was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].AttyState_ft[0] (0.62 conf)
v_page_p_header_info_zip_ft was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].AttyZip_ft[0] (0.39 conf)
v_page_p_header_info_city_ft was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].AttyCity_ft[0] (0.41 conf)
v_page_p_header_info_ft__1 was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].AttyStreet_ft[0] (0.41 conf)
ci_v_page_p_header_atty_info_firm_ft was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].AttyFirm_ft[0] (0.44 conf)
v_page_p_header_info_name_ft was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].AttyName_ft[0] (0.46 conf)
ci_v_page_p_header_info_dc was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].AttyBarNo_dc[0] (0.40 conf)
v_page_p_header_info_ft__2 was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].Phone_ft[0] (0.42 conf)
ci_v_page_p_header_atty_info_fax_ft was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].Fax_ft[0] (0.43 conf)
v_page_p_header_info_email was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].Email_ft[0] (0.41 conf)
ci_v_page_p_header_info_ft was CIV-105[0].Page1[0].P1Header[0].AttyInfo[0].AttyFor_ft[0] (0.44 conf)
v_page_p_court_info_county was CIV-105[0].Page1[0].P1Header[0].CourtInfo[0].CrtCounty_ft[0] (0.36 conf)
v_page_p_court_info_branch was CIV-105[0].Page1[0].P1Header[0].CourtInfo[0].Branch_ft[0] (0.40 conf)
v_page_p_header_info_city was CIV-105[0].Page1[0].P1Header[0].CourtInfo[0].CityZip_ft[0] (0.39 conf)
v_page_p_info_street_ft was CIV-105[0].Page1[0].P1Header[0].CourtInfo[0].Street_ft[0] (0.43 conf)
ci_v_page_p_header_court_info_mailing_add_ft was CIV-105[0].Page1[0].P1Header[0].CourtInfo[0].MailingAdd_ft[0] (0.38 conf)
v_page_p_title_party_name__1 was CIV-105[0].Page1[0].P1Header[0].TitlePartyName[0].Party1_ft[0] (0.37 conf)
v_page_p_title_party_name__2 was CIV-105[0].Page1[0].P1Header[0].TitlePartyName[0].Party2_ft[0] (0.37 conf)
page_form_title_area_check_box__1 was CIV-105[0].Page1[0].P1Header[0].FormTitle[0].#area[0].CheckBox12436234346[0] (0.38 conf)
page_form_title_area_check_box__2 was CIV-105[0].Page1[0].P1Header[0].FormTitle[0].#area[1].CheckBox12t342563426y[0] (0.38 conf)
ci_v_page_p_header_case_number__1 was CIV-105[0].Page1[0].P1Header[0].CaseNumber[0].CaseNumber[0] (0.42 conf)
ci_v_page_list_lia_date_field was CIV-105[0].Page1[0].List1[0].Lia[0].DateField1[0] (0.36 conf)
ci_v_page_list_lib_fill_text was CIV-105[0].Page1[0].List1[0].Lib[0].FillText99[0] (0.41 conf)
ci_v_page_list_lic_check_box was CIV-105[0].Page1[0].List1[0].Lic[0].CheckBox9[0] (0.36 conf)
ci_v_page_list_lic_text_field was CIV-105[0].Page1[0].List1[0].Lic[0].TextField6[0] (0.36 conf)
ci_v_page_list_lid_check_box was CIV-105[0].Page1[0].List1[0].Lid[0].CheckBox8[0] (0.36 conf)
ci_v_page_list_lid_text_field was CIV-105[0].Page1[0].List1[0].Lid[0].TextField2[0] (0.36 conf)
ci_v_page_list_lie_check_box was CIV-105[0].Page1[0].List1[0].Lie[0].CheckBox3[0] (0.36 conf)
ci_v_page_list_lie_fill_text was CIV-105[0].Page1[0].List1[0].Lie[0].FillText102[0] (0.41 conf)
ci_v_page_list_li_fill_text__1 was CIV-105[0].Page1[0].List2[0].Li2a[0].FillText68[0] (0.41 conf)
ci_v_page_list_li_fill_text__2 was CIV-105[0].Page1[0].List2[0].Li2a[0].FillText67[0] (0.41 conf)
ci_v_page_list_li_fill_text__3 was CIV-105[0].Page1[0].List2[0].Li2a[0].FillText66[0] (0.41 conf)
ci_v_page_list_li_b_fill_text__1 was CIV-105[0].Page1[0].List2[0].Li2b[0].FillText59[0] (0.41 conf)
ci_v_page_list_li_b_fill_text__2 was CIV-105[0].Page1[0].List2[0].Li2b[0].FillText58[0] (0.41 conf)
ci_v_page_list_li_b_fill_text__3 was CIV-105[0].Page1[0].List2[0].Li2b[0].FillText57[0] (0.41 conf)
ci_v_page_list_li_c_fill_text__1 was CIV-105[0].Page1[0].List2[0].Li2c[0].FillText56[0] (0.41 conf)
ci_v_page_list_li_c_fill_text__2 was CIV-105[0].Page1[0].List2[0].Li2c[0].FillText55[0] (0.41 conf)
ci_v_page_list_li_c_fill_text__3 was CIV-105[0].Page1[0].List2[0].Li2c[0].FillText54[0] (0.41 conf)
ci_v_page_list_li_fill_text__4 was CIV-105[0].Page1[0].List2[0].Li2d[0].FillText53[0] (0.41 conf)
ci_v_page_list_li_fill_text__5 was CIV-105[0].Page1[0].List2[0].Li2d[0].FillText52[0] (0.41 conf)
ci_v_page_list_li_fill_text__6 was CIV-105[0].Page1[0].List2[0].Li2d[0].FillText51[0] (0.41 conf)
ci_v_page_list_e_fill_text__1 was CIV-105[0].Page1[0].List2[0].Li2e[0].FillText73[0] (0.41 conf)
ci_v_page_list_e_fill_text__2 was CIV-105[0].Page1[0].List2[0].Li2e[0].FillText72[0] (0.41 conf)
ci_v_page_list_e_fill_text__3 was CIV-105[0].Page1[0].List2[0].Li2e[0].FillText71[0] (0.41 conf)
ci_v_page_p_header_case_number__2 was CIV-105[0].Page2[0].P2Header[0].CaseNumber[0].CaseNumber[0] (0.42 conf)
v_page_p_title_party_name__3 was CIV-105[0].Page2[0].P2Header[0].TitlePartyName[0].Party1_ft[0] (0.37 conf)
v_page_p_title_party_name__4 was CIV-105[0].Page2[0].P2Header[0].TitlePartyName[0].Party2_ft[0] (0.37 conf)
ci_v_page_signature_fill_text was CIV-105[0].Page2[0].Signature[0].FillText70[0] (0.40 conf)
ci_v_page_signature_date_field was CIV-105[0].Page2[0].Signature[0].DateField1[0] (0.37 conf)
ci_v_page_court_use__1 was CIV-105[0].Page2[0].CourtUse[0].T226[0] (0.34 conf)
ci_v_page_court_use__2 was CIV-105[0].Page2[0].CourtUse[0].T226[1] (0.34 conf)
v_page_court_use_date_field was CIV-105[0].Page2[0].CourtUse[0].DateField1[0] (0.38 conf)
page_list_instructions_check_box__1 was CIV-105[0].Page2[0].List6[0].Instructions[0].CheckBox26[0] (0.36 conf)
page_list_instructions_check_box__2 was CIV-105[0].Page2[0].List6[0].Instructions[0].CheckBox26[1] (0.36 conf)
ci_v_page_list_li_fill_text__7 was CIV-105[0].Page2[0].List6[0].Li6a[0].FillText119[0] (0.41 conf)
ci_v_page_list_li_b_fill_text__4 was CIV-105[0].Page2[0].List6[0].Li6b[0].FillText120[0] (0.41 conf)
ci_v_page_list_li_c_fill_text__4 was CIV-105[0].Page2[0].List6[0].Li6c[0].FillText123[0] (0.41 conf)
ci_v_page_list_li_fill_text__8 was CIV-105[0].Page2[0].List6[0].Li6d[0].FillText124[0] (0.41 conf)
ci_v_page_list_e_fill_text__4 was CIV-105[0].Page2[0].List6[0].Li6e[0].FillText125[0] (0.41 conf)
ci_v_page_list_li_f_date_field was CIV-105[0].Page2[0].List6[0].Li6f[0].DateField1[0] (0.36 conf)
ci_v_page_list_check_box was CIV-105[0].Page2[0].List7[0].CheckBox25[0] (0.34 conf)
ci_v_page_list_li_check_box__1 was CIV-105[0].Page2[0].List7[0].Li7a[0].CheckBox24[0] (0.36 conf)
ci_v_page_list_li_check_box__2 was CIV-105[0].Page2[0].List7[0].Li7a[0].CheckBox24[1] (0.36 conf)
ci_v_page_list_li_b_check_box__1 was CIV-105[0].Page2[0].List7[0].Li7b[0].CheckBox23[0] (0.36 conf)
ci_v_page_list_li_b_check_box__2 was CIV-105[0].Page2[0].List7[0].Li7b[0].CheckBox23[1] (0.36 conf)
ci_v_page_p_header_case_number__3 was CIV-105[0].Page3[0].P3Header[0].CaseNumber[0].CaseNumber[0] (0.42 conf)
v_page_p_title_party_name__5 was CIV-105[0].Page3[0].P3Header[0].TitlePartyName[0].Party1_ft[0] (0.37 conf)
v_page_p_title_party_name__6 was CIV-105[0].Page3[0].P3Header[0].TitlePartyName[0].Party2_ft[0] (0.37 conf)
ci_v_page_list_li_check_box__3 was CIV-105[0].Page3[0].List8[0].Li8a[0].CheckBox18[0] (0.36 conf)
ci_v_page_list_li_text_field was CIV-105[0].Page3[0].List8[0].Li8a[0].TextField6[0] (0.36 conf)
ci_v_page_list_li_b_check_box__3 was CIV-105[0].Page3[0].List8[0].Li8b[0].CheckBox18[0] (0.36 conf)
ci_v_page_list_li_b_sublib_fill_text was CIV-105[0].Page3[0].List8[0].Li8b[0].Sublib[0].Li8b1[0].FillText130[0] (0.38 conf)
ci_v_page_list_li_b_sublib_date_field was CIV-105[0].Page3[0].List8[0].Li8b[0].Sublib[0].Li8b2[0].DateField1[0] (0.36 conf)
ci_v_page_declaration_fill_text__1 was CIV-105[0].Page3[0].Declaration[0].FillText117[0] (0.40 conf)
v_page_declaration_date_field__1 was CIV-105[0].Page3[0].Declaration[0].DateField1[0] (0.37 conf)
ci_v_page_list_li_check_box__4 was CIV-105[0].Page3[0].List9[0].Li9a[0].CheckBox19\.3[0] (0.36 conf)
ci_v_page_list_li_b_cb was CIV-105[0].Page3[0].List9[0].Li9b[0].cb9b[0] (0.32 conf)
ci_v_page_list_li_c_cb was CIV-105[0].Page3[0].List9[0].Li9c[0].cb9c[0] (0.32 conf)
ci_v_page_list_li_cb was CIV-105[0].Page3[0].List9[0].Li9d[0].cb9d[0] (0.32 conf)
ci_v_page_list_li_fill_text__9 was CIV-105[0].Page3[0].List9[0].Li9d[0].FillText135[0] (0.41 conf)
ci_v_page_list_li_e_cb was CIV-105[0].Page3[0].List9[0].Li9e[0].cb9e[0] (0.32 conf)
ci_v_page_list_li_e_cb_ei was CIV-105[0].Page3[0].List9[0].Li9e[0].cb9ei[0] (0.32 conf)
ci_v_page_list_li_e_cb_ea was CIV-105[0].Page3[0].List9[0].Li9e[0].cb9ea[0] (0.32 conf)
ci_v_page_list_li_f_cb was CIV-105[0].Page3[0].List9[0].Li9f[0].cb9f[0] (0.32 conf)
ci_v_page_list_li_f_text_field was CIV-105[0].Page3[0].List9[0].Li9f[0].TextField6[0] (0.36 conf)
ci_v_page_list_li_fill_text__10 was CIV-105[0].Page3[0].List10[0].Li10a[0].FillText136[0] (0.41 conf)
ci_v_page_list_li_b_fill_text__5 was CIV-105[0].Page3[0].List10[0].Li10b[0].FillText136[0] (0.41 conf)
ci_v_page_list_li_c was CIV-105[0].Page3[0].List10[0].Li10c[0].T163[0] (0.36 conf)
ci_v_page_list_li_c_fill_text__5 was CIV-105[0].Page3[0].List10[0].Li10c[0].FillText138[0] (0.41 conf)
ci_v_page_list_li_fill_text__11 was CIV-105[0].Page3[0].List10[0].Li10d[0].FillText140[0] (0.41 conf)
ci_v_page_list_li_fill_text__12 was CIV-105[0].Page3[0].List10[0].Li10d[0].FillText139[0] (0.41 conf)
ci_v_page_list_e_fill_text__5 was CIV-105[0].Page3[0].List10[0].Li10e[0].FillText116[0] (0.41 conf)
ci_v_page_list_li_f_check_box was CIV-105[0].Page3[0].List10[0].Li10f[0].CheckBox16[0] (0.36 conf)
ci_v_page_declaration_fill_text__2 was CIV-105[0].Page3[0].Declaration2[0].FillText117[0] (0.40 conf)
v_page_declaration_date_field__2 was CIV-105[0].Page3[0].Declaration2[0].DateField1[0] (0.37 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

v_page_p_header_info_state
v_page_p_header_info_zip_ft
v_page_p_header_info_city_ft
v_page_p_header_info_ft__1
ci_v_page_p_header_atty_info_firm_ft
v_page_p_header_info_name_ft
ci_v_page_p_header_info_dc
v_page_p_header_info_ft__2
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