Commonwealth of Massachusetts
S U F F O L K , s s .
TRIAL COURT OF THE COMMONWEALTH
BOSTON MUNICIPAL COURT DEPARTMENT
Civil N o .
P laintiff(s )
REQUEST FOR DEFAULT
( P u r s u a n t t o R u l e 5 5 ( a ) )
D efe nda n t(s)
To the Clerk of th e above -n a m ed Cou rt:
I , atto rney fo r the above-na m e d p lain tiff(s),
state tha t the com p laint in w hich a judgm en t fo r affirm ative re lief is
sou ght aga inst th e defen d ant(s) herein, w as filed o n
and the sum m o n s and a cop y of the com plain t have been serv ed on the d e fen dan t(s) h erein
on as app e a rs from the o ffic e r's return; th at the tim e w ith in w hich the defend ant(s) s ha ll
se rve a responsive pleading or otherwise defend pu rsuan t to Ru le 1 2 (a ), h a s expire d and the defend ant(s ) h er e in
has/h ave failed to serve or file an answ er o r otherw is e defend a s to th e co m p la in t.
W h e r e fore, the plain tiff(s) m a k e (s ) a p p l i ca t io n th a t t h e
defen d ant(s) be defa u lted .
SIG N E D U N D E R TH E PE N A LT IE S O F P E R JU R Y
Signed
Print or Type Atty. for Plff
Print or Type Address
Tel. No.
BBO No.
PLAINTIFF'S REQUEST FOR JUDGMENT FOR RELIEF
(Pursu ant to R u le 5 5 (b )(1))
Th e und ersign e d re q u ests that ju dgm en t enter again st the defe n da n t(s)
in the a m o un t of $ together w ith interest in the sum o f $ w ith c o sts an d m a ke
affida v it th a t:
1. T h e to ta l am o u n t d u e th e p la i n tif f ( s ) , ex c l u si v e o f c o s ts i n t h e c l a im ag a in s t t h e d e fe n d a n t ( s ), i s
$ .
2. Th a t the d efendan t(s) is/are n ot a n infant or incom p etent p e r s o n.
3. Th a t th e d e fen d ant(s) is/are no t in the m ilitary service of the U nited S tates or its A llies, as d efin ed
in th e Servicem em b e r s C ivil Relie f A ct of 200 3 , as set fo rth in 50 U .S .C . App . §§ 50 1 et seq.,
evidenc ed by th e follow in g facts:
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)
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 .
