AFFIDAVIT OF NON-COMPLIANCE REGISTRY FILE NUMBER

IN THE PROVINCIAL COURT OF BRITISH COLUMBIA REGISTRY LOCATION

(Small Claims Court)

IN THE CASE BETWEEN

CLAIMANT(S)

AFFIDAVIT OF NON-COMPLIANCE
Fill in the Registry File
number and location. NAME

Copy the names and ADDRESS

addresses of the claim-
ant, defendant or third British Columbia
party. CITY, TOWN, MUNICIPALITY PROV. POSTAL CODE TEL. #

AND
DEFENDANT(S)
NAME

ADDRESS

British Columbia
CITY, TOWN, MUNICIPALITY PROV. POSTAL CODE TEL. #

AND
THIRD PARTY(S)
NAME

ADDRESS

British Columbia
CITY, TOWN, MUNICIPALITY PROV. POSTAL CODE TEL. #

I
NAME OCCUPATION
of
ADDRESS

make oath and say that

solemnly affirm that

Attach this Affidavit 1. I am the in this action and this is my

to a completed
”Payment Order“ Affidavit in support of the attached Payment Order.

2. An agreement was recorded at a settlement conference on

DATE
mediation

3. The Claimant
What happened in Defendant
this case? Explain.
Third Party
Failed to comply with the recorded terms of the agreement by

Do not sign your

affidavit until a
commissioner for the month day year signature of person filling out the affidavit
taking of affidavits is
present.
Sworn / Affirmed before me on
A commissioner for
taking affidavits will at
witness your signature month day year location where affidavit is sworn

signature of commissioner for taking affidavits for British Columbia

SCL 808 12/2006