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My name is John Elliot. On January 11, 20xx, a judgment was awarded against me in small claims court in Ithaca, New York (Case # 1234). On March 20, 20xx, I paid Beatrice Small, the prevailing party, $1,200, the full amount of this judgment [or, if payments were made in installments–"I paid Beatrice Small, the prevailing party in this action, installments of the following amounts on the following dates: _______________ , concluding with a final payment of $________ on March 20, 20xx."]
I attach to this statement a canceled check [or other proof that the judgment was paid] for the full amount of the judgment endorsed by Beatrice Small. [If payment was made by money order or cash (with a receipt), modify this statement as needed. If payment was made in installments, modify this statement as needed and enclose copies of all canceled checks.]
Beatrice Small did not voluntarily file a Satisfaction of Judgment. When I tried to contact her, I learned that she had moved and had left no forwarding address. [If the judgment creditor refuses to sign a Satisfaction of Judgment form, or is otherwise not available to do so, modify this statement as necessary.]
I declare under penalty of perjury under the laws of the State of
_______________________ that the foregoing is true and correct.
DATED: June 4, 20xx. ______________________
John Elliot