COMMONWEALTH OF MASSACHUSETTS 

________________,SS:

     HOUSING COURT DEPARTMENT
_______________ DIVISION

     /  /  / - /  /  /  /  /  /
     SMALL CLAIMS NO.
     

STATEMENT OF FAILURE TO COMPLY WITH RULE 7(G)

(Please print clearly or type)

I, ___________________________________________________________________

(First Name)

(MI.)

(Last Name) (If Corporation or Trust,        
                   list name of principal         
                   officer and title)

the prevailing party in the action, residing at:

_____________________________________________________________________
(No.)

(City/Town)

(Address)

______________________________________  state that __________________
(State)

(First Name)

(Zip Code)

_____________________________________________________________________
(MI.)

(Last Name)

(If Corporation/Trust list name of principal   
officer)

residing at __________________________________________________________
(State)   (Zip)

 (No.)    (Address)

(City/Town)

the respondent, has failed to obey the order of payment.  I request further
that this Court make appropriate orders to ensure compliance with the order
of payment, and order the respondent to pay my costs of service.  

Signed under the pains and penalties of perjury this _________________

day of ____________________ 20_____.

________________________________
(Prevailing Party)

________________________________

________________________________

________________________________

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