Free Stipulation of Settlement and Affidavit Upon Default - New York

Civil Court of the City of New York COUNTY OF
Part

Index No. STIPULATION OF SETTLEMENT and AFFIDAVIT UPON DEFAULT

Claimant(s), Plaintiff(s), -aga ins t-

Defendant(s).

STIPULATION OF SETTLEMENT
It is hereby agreed by and between the parties that this claim is settled for the sum of $
(Amount)

, to be at:
(Creditor)

paid by
(Debtor)

, on or before
(Date) (Address)

to or as follows:

Upon such payment all parties shall be released from liability to each other concerning the matters in this dispute. In the event Debtor fails to make payment as agreed to above, Creditor, upon completing the Affidavit below setting forth such default, shall be entitled to: (SELECT ONE OPTION) a) enter Judgment, without further notice to the Debtor, for the amount (originally sued for/agreed to above) less any payments made, together with interest and disbursements. (Cross out inapplicable choice) b) restore the case to the calendar for trial.

Signature

Date

Signature

Date

Signature

Date

Signature

Date

AFFIDAVIT UPON DEFAULT OF STIPULATION
State of New York, County of SS: , being duly sworn, deposes and says:
(Creditor)

This case was settled as indicated above. The Debtor has failed to comply with the terms of the settlement. I,

(Specify your request)

Sworn to before me this day of 20

(Notary Public or Court Employee and Title)

Signature of Deponent

CIV-GP-31-i (Revised 1/03)
FREE CIVIL COURT FORM No fee may be charged to fill in this form. Form can be found at: http://www.nycourts.gov/courts/nyc/smallclaims/forms.shtml.