Affidavit In Support Of Application For Entry Of Fact Of Default Page 7

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Revised 1/2005
Suggested Form D105
UNITED STATES BANKRUPTCY COURT
WESTERN DISTRICT OF NEW YORK
In Re:
AFFIDAVIT OF AMOUNT DUE
(Non-Core Proceeding)
Debtor (s).
BK Case No. ____________
Plaintiff (s),
vs.
AP Case No. ____________
Defendant (s).
In support of the Plaintiff’s request that the Bankruptcy Court recommend and the District Court enter
Judgment by Default against the Defendant, ______________________________________ (“Defendant”),
Plaintiff submits the following itemization of damages sought:
Principal amount prayed for in Complaint
$__________
1
Pre-judgment interest
$__________
Cost
$__________
2
Attorney’s Fees
$__________
$__________
TOTAL DAMAGES
Plus per diem of $__________
$__________
since the date of the filing
Plaintiff’s request for default
$__________
TOTAL DEFAULT JUDGMENT REQUESTED
Date: _________________
______________________________
Attorney for Plaintiff or Plaintiff pro se
Sworn to before me
this ______ day of _________________, 2_____
_______________________________________
Notary
1
Based on 28 U.S.C. § 1961; at the rate of _____% since _________________, through the date of the filing of the request
(to be computed by Plaintiff).
2
See, 28 U.S.C. § 1923.

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