Commonwealth of Massachusetts

S U  F F O  L K  ,  s s .                                                                                                                  TRIAL  COURT  OF  THE  COMMONWEALTH
BOSTON  MUNICIPAL  COURT  DEPARTMENT

            C iv il N o .

        REQUEST FOR DEFAULT
   ( P u r s u a n t  t o  R u l e  5 5  ( a ) )

P la in tiff(s )

D e fe n d a n t(s )

I 

T o  th e  C le rk  o f th e  a bo v e -n a m e d  C o u rt:

 s ta te  th a t th e  c o m p la in t in  w h ic h  a  ju d g m en t fo r a ffirm a tiv e  re lie f is

, a tto rn e y  fo r th e a b o v e -n a m e d  p la in tiff(s ),

s o u g h t a ga in s t th e  d e fe n d a n t(s ) 

h e re in , w a s file d  o n

 a n d  th e  s u m m o n s  a n d  a  c o p y  o f th e  c o m p la in t h a v e  b e e n  s erv ed  o n  th e  d e fe n d a n t(s ) h e re in

o n  

       a s  a p p e a rs  fro m  th e  o ffice r's  re tu rn ; th a t th e  tim e  w ith in  w h ich  th e d e fe n d a n t(s ) s h a l l

s e r v e  a  re s p o n s iv e  p le a d in g o r o th e rw is e  d e fe n d  p u rs u a n t to  R u le  1 2 (a ), h a s  e x p ire d  a n d  th e  d efe n d a n t (s ) h e r e in

h a s / h a v e  fa ile d  to  s e rv e  o r file  a n  a n s w e r o r o th e rw is e  d e fe n d  a s  to  th e  c o m p la in t.

W h e re fo re , th e  p la in tiff(s )

d e fe n d a n t(s ) 

m a k e ( s )   a p p l i c a t i o n  t h a t  t h e

b e  d efa u lte d .  

D  a t e d  a t  B o s t o n ,  M  a s s a c h u s e t t s ,  t h i s 

            d a y  o f 

    , 2 0 

.

S IG N E D  U N D E R  T H E  P E N A L T IE S  O F  P E R J U R Y

      Signed

      Print or Type

      Print or Type

      Tel. No. 

      BBO No. 

Atty. for Plff

Address

PLAINTIFF'S REQUEST FOR JUDGMENT FOR RELIEF
(P u rs u a n t to  R u le  5 5  (b )(1 ))

T h e u n d e rs ig n ed  re q u es ts  th a t ju d g m e n t en te r a g a in s t th e  d efen d a n t(s ) 

 in  th e  a m o u n t o f $  

a ffid a v it th a t:

to g e th e r w ith  in te re s t in  th e  s u m  o f $

     w ith  c o s ts  a n d  m a k e

1.

2.

3.

T h e  t o t a l  a m o u n t  d u e  t h e  p l a i n t i f f ( s ) ,  e x c l u s i v e  o f  c o s t s  i n  t h e  c l a i m  a g a i n s t  t h e  d e f e n d a n t ( s ) ,  i s
$
T h a t th e  d e fe n d a n t(s ) is / a re  n o t a n  in fa n t o r in c o m p e te n t p e rs o n .

     . 

T h a t th e  d e fe n d a n t(s ) is / a re  n o t in  th e  m ilita ry  s e rv ic e  o f th e U n ite d  S ta tes  o r its  A llie s , a s  d e fin e d
in   th e   S e rv ic em e m b e rs   C iv il  R e lie f  A ct  o f  2 0 0 3 ,  a s   s e t  fo rth   in   5 0   U .S .C .  A p p .  § §   5 0 1   e t  s e q .,
e v id e n c ed  b y  th e  fo llo w in g  fa c ts : 

S u b s c r i b e d  t h i s 

         d a y  o f 

   ,  2 0 

            u n d e r  t h e  p e n a l t i e s  o f  p e r j u r y .

E  x e c u t i o n  r e q u e s t e d .

P l a i n t i f f .

BMC-CV-005 

R E Q  U  E S T  F O  R  D  E F A U  L T  A N  D  D E F A  U  L T  J U  D  G  M  E N  T                                  (Rev.  06/10   swf)