AGREEMENT FOR JUDGMENT
AND FOR PAYM ENT ORDER

D O C K E T N U MB E R

Trial Court of Massachusetts
Small Claims Session

P LA IN T IFF(S ) W H O  A R E  P A R T IE S  T O  T H IS  A G R E E M E N T  

C O U R T  D IV IS IO N

D E FE N D A N T (S ) W H O  A R E  PA R TIE S  T O  T H IS  AG R E E ME N T

R E Q U E ST E D  D A T E  O F P AYM EN T  R E V IE W

VS.

G  C heck here if defendant has m oved and write new address above or on back of court copy

G  N o payment review requested

G JUDGMENT FOR PLAINTIFF(S).  It is hereby agreed that in this small claim the Court may enter a judgment 

for the plaintiff(s) named above and against the defendant(s) named above for:

_____________  DAMAGES

G Plus PREJUDGMENT INTEREST from ___________________ (date)

$

$

$

_____________  COSTS

_____________  ATTORNEY FEES

at the 12% statutory rate or the _______% contractual rate

G Prejudgment interest is waived by the plaintiff.

(if authorized by contract or statute)

G Postjudgment interest is waived by the plaintiff.

PAYMENT ORDER.  It is also agreed that the Court may enter a payment order that requires the defendant(s):

G to pay the plaintiff(s) the total amount of the judgment on or before __________________________________ (date).

G to pay the plaintiff(s) $ ______________ each  G week  G month  beginning on ________________ (date)

until the total amount of the judgment is paid in full.

This payment order will not be satisfied with any exempt income listed on pg. 2 of this form.

G REVISED PAYMENT ORDER.  In this small claim the Court has already entered a judgment and it is hereby agreed that the Court

may revise that payment order as follows:

This payment order will not be satisfied with any exempt income listed on pg. 2 of this form.

G SATISFIED IN FULL.  It is also agreed that this claim or judgment has already been satisfied in full.

(By court rule plaintiff(s) must file an acknowledgment of satisfaction with the court when the judgment has been paid in full.)

G JUDGMENT FOR DEFENDANT(S).  It is hereby agreed that in this small claim the Court may enter a judgment 

for the defendant(s) named above, and the plaintiff(s) shall take nothing on this claim.

G DISMISSAL.  It is hereby agreed that the Court may enter a judgment dismissing this small claim.

G JUDGMENT ON COUNTERCLAIM.  It is also agreed that the Court may enter the following judgment on the counterclaim brought 

by the above-named defendant(s) against the above-named plaintiff(s):

O T H E R  P R O V IS IO N S  O R  C O M M E N T S

U pon acceptance by the C ourt, a judgm ent and paym ent order will be entered in accordance with the above term s and will be enforceable as an order of the C ourt.

  X    
S IG N A T U R E  O F  P LA IN T IFF(S ) O R  A T T O R N E Y FO R  P LA IN T IFF(S )

P R IN T  N A M E

  X    
S IG N A T U R E  O F  D E F E N D A N T (S ) O R  A T T O R N E Y FO R  D E FE N D A N T (S )

P R IN T  N A M E

RECORD OF COURT REVIEW  (For optional use by magistrate)

G T o be entered as court’s judgm ent and/or paym ent order.   G A greem ent was subm itted in open court and R ule 7(a) inquiry m ade of defendant(s) as to any paym ent order.

DC-SC-8 (11/18)  

  www.m ass.gov/courts/districtcourt

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C LE R K -M AG IS T R A TE  / A SS T . C LE R K

____________________
D A T E

_ __________________
D A T E

INCOME AND PROPERTY 
THAT ARE 
EXEMPT FROM PAYMENT ORDERS 

(This list of exempt income and property is not comprehensive. It is provided to assist the court in avoiding 
the  issuance  of  orders  that  would  require  payment  from  exempt  sources.  When  requesting  a  payment 
order,  the  creditor  bears  the  burden  of  proving  that  the  debtor  has  sufficient  non-exempt  income  or 
property with which to satisfy the judgment. See G.L. c. 224, § 16.) 

1. INCOME FROM THE FOLLOWING SOURCES is exempt by law from payment orders:

• Unemployment Benefits (G.L. c. 151A, § 36)
• Workers Compensation Benefits (G.L. c. 152, § 47)
• Social Security Benefits (42 U.S.C. § 401)
• Federal Old-Age, Survivors & Disability Insurance Benefits (42 U.S.C. § 407)
• Supplementary Security Income (SSI) for Aged, Blind & Disabled (42 U.S.C. § 1383[d][1])
• Other Disability Insurance Benefits up to $400 weekly (G.L. c. 175, § 110A)
• Emergency Aid for Elderly & Disabled (G.L. c. 117A)
• Veterans Benefits

• Federal Veterans Benefits (38 U.S.C. § 5301[a])
• Special Benefits for Certain WW II Veterans (42 U.S.C. § 1001)
• Medal of Honor Veterans Benefits (38 U.S.C. § 1562)
• State Veterans Benefits (G.L. c. 115, § 5)

• Transitional Aid to Families with Dependent Children (AFDC) Benefits (G.L. c. 118, § 10)
• Maternal Child Health Services Block Grant Benefits (42 U.S.C. § 701)
• Other public assistance benefits (G.L. c. 235, § 34, cl. fifteenth)
• Payouts from certain Massachusetts employee pension plans (G.L. c. 32, § 19)

2. Certain PERSONAL AND REAL PROPERTY is also exempt from payment orders, including:
• $2,500 in cash or savings or other deposits in a banking or investment institution (G.L. c. 235, § 34, cl.

fifteenth)

• Automobile or vehicle up to exemption limit (G.L. c. 235, § 34, cl. sixteenth)
• Other specific types of personal property are exempt under other clauses of G.L. c. 235, § 34
• Real estate subject to automatic or declared homestead exemption (G.L. c. 188) and, in lieu thereof, the

amount of money necessary for rent, up to $2,500 per month (G.L. c. 235, § 34, cl. fourteenth)

• There are also exemptions for “aggregate” amounts, up to maximum limits, of certain unused exemptions

(G.L. c. 235, § 34, cl. seventeenth)

3. In addition, A PORTION OF WAGES AND CONTRIBUTIONS TO EMPLOYMENT-BASED

RETIREMENT PLANS is exempt by law from payment orders.

Massachusetts law exempts the greater of 85% of the debtor’s gross earnings or 50 times the greater of 
the Federal minimum wage ($7.25 as of 7/24/09) or the Massachusetts minimum wage ($11/hr. until 
12/31/18 per G.L. c. 151, § 1; $12/hr. as of 1/1/19; $12.75/hr. as of 1/1/20; $13.50/hr. as of 1/1/21; 
$14.25/hr. as of 1/1/22; and $15/hr. as of 1/1/23) for each week or portion thereof (G.L. c. 224, § 16 & c. 
235, § 34, cl. fifteenth). The amount exempt under federal law (15 U.S.C. §§1671-1677) may exceed the 
Massachusetts exemption. If so, the federal exemption applies. 

See Worksheet for Computing Amount of Wages Exempt From Attachment, Execution and Payment 
Orders. https://www.mass.gov/media/910531/download/  

Rev. 11/18