Form 4-805C. Application for writ of execution (medical debt judgment).

[For use with Rules 1-065.1, 2-801, and 3-801 NMRA] STATE OF NEW MEXICO COUNTY OF ______________________________ IN THE ________________________ COURT ________________________________________ Plaintiff v. No. ____________ ________________________________________ Defendant APPLICATION FOR WRIT OF EXECUTION (MEDICAL DEBT JUDGMENT) ________________________________________, the judgment creditor, states: (1) The underlying judgment is based on a cause of action to recover judgment for medical debt under the Patients’ Debt Collection Protection Act, NMSA 1978, Section 57-32-1 to 57-32-10. (2) The judgment creditor has a judgment dated ________________________ (date judgment filed) against the judgment debtor whose name is ________________________, and whose last known address is ________________________. The total of the principal, interest, costs, and attorney’s fees awarded by the judgment was $ ______________. Since the judgment was entered, additional interest at the judgment rate of __________% and costs total $ ______________. Payments totaling $ ______________ have been received. The unpaid balance now due is $ ______________ plus interest from the date this Application is executed. The estimated costs would equal $ ______________; and the judgment creditor will seek $ ______________ in attorney fees. (3) (check one of the following) [ ] In compliance with NMSA 1978, Section 57-32-4 and 13.10.39.9 NMAC, judgment creditor has determined that the judgment debtor is not now an indigent patient as defined in NMSA 1978, Section 57-32-2(G); OR [ ] Judgment creditor has determined the judgment debtor is not now indigent based on information and belief, and was unable to determine otherwise due to the noncooperation by the judgment debtor. In compliance with 13.10.39.9(A)(b) NMAC, judgment creditor affirms that it made at least three documented efforts to contact the judgment debtor as follows: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (4) The judgment debtor is a natural person, and no later than ten (10) days before filing this application for writ of execution: [ ] I served the judgment debtor with: (a) notice of right to claim exemptions;1 (b) a claim of exemptions on execution;2 and (c) a copy of the current Attestation of Indigency form promulgated by the New Mexico Superintendent of Insurance;3 AND (check one of the following) [ ] Within ten (10) days after service of the documents listed in Paragraph 4, the judgment debtor has filed an Attestation of Indigency form or other proof of indigency, or a claim of exemption(s) for the property to be seized and sold, and has served a copy on the judgment creditor. The judgment creditor disputes the judgment debtor’s assertion of indigency or claimed exemption(s) and requests a hearing be held on this dispute. or [ ] Within ten (10) days after service of the documents listed in Paragraph 4, the judgment debtor has not requested a determination of indigency or filed a claim of exemption for the property to be seized and sold. The judgment creditor requests the court to issue a Writ of Execution for the non-exempt property for the judgment debt. _________________________________ Judgment creditor or attorney for judgment creditor _________________________________ Judgment creditor’s name printed _________________________________ Judgment creditor’s name printed _________________________________ Address of judgment creditor _________________________________ Printed name of person signing for judgment creditor _________________________________ Telephone of judgment creditor __________________________________________________ Printed name of judgment creditor’s attorney (if any) __________________________________________________ Mailing address of judgment creditor’s attorney (number and street or P.O. box) __________________________________________________ City, State, zip code __________________________________________________ Telephone number of judgment creditor’s attorney AFFIDAVIT (This application must be sworn to unless it is signed by an attorney.) I declare under penalty of perjury that the foregoing is true and correct. Subscribed and sworn to before me this __________ day of ______________, __________. (seal) _____________________________________ Notary or other officer authorized to administer oaths