STATE OF RHODE ISLAND AND
PROVIDENCE PLANTATIONS
DISTRICT COURT
AFFIDAVIT
The undersigned, being duly sworn, upon oath deposes and says:
1. That I am the Plaintiff and have personal knowledge of the facts set forth in this affidavit;
2. That the Plaintiff on the __________ day of ___________________, 20_____, filed in
this action a Complaint against the Defendant;
3. That examination of the court’s records in this action shows that the Defendant was duly
served with a copy of the Summons and a copy of the Plaintiff’s Complaint;
4. That more than _____ days have elapsed since service of the Summons and Complaint;
5. That the Defendant has failed to plead or otherwise defend as to the Plaintiff’s Complaint;
and
6. That this Affidavit is executed by the affiant herein in accordance with Rule 55(a) of the
Rhode Island District Court Rules of Civil Procedure for the purpose of enabling the Plaintiff to
obtain an Entry of Default against the Defendant for failure to plead or otherwise defend as to the
Plaintiff’s Complaint.
________________________________
Signature of the Plaintiff
State of _______________________________
County of _____________________________
On this ________ day of ________________, 20____, before me, the undersigned notary
public, personally appeared _____________________________________________________
personally known to the notary or proved to the notary through satisfactory evidence of
identification, which was _____________________________________________________, to
be the person who signed above in my presence, and who swore or affirmed to the notary that the
contents of the document are truthful to the best of his or her knowledge.
Notary Public: ____________________________________
My commission expires: ____________________________
Notary identification number: ________________________
DC-36 (revised May 2016)
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