COMMONWEALTH OF MASSACHUSETTS
DISTRICT COURT DEPARTMENT
DIVISION
DOCKET NO.
REQUEST FOR DEFAULT
(Rule 55 (a))
I, __________________________________________________________ the undersigned, for the above-named plaintiff(s)
____________________________________________, state that the complaint in this action was filed on __________________,
and the summons and a copy of the complaint were served on defendant(s) ______________________________________ on
_______________________, as appears from the officer's return; and that the defendant(s) herein has (have) failed to serve a
responsive pleading or to otherwise defend as provided by rule.
Therefore, I request that default be entered against defendant(s) _______________________________________________
in this action.
Signed under the penalties of perjury.
Signature_____________________________________________
Name_________________________________________________
Address_______________________________________________
_____________________________________________________
Telephone _____________________________________________
________________________________________________________________
v.
________________________________________________________________
DATE
________________________