(Caption)

Notice of Intention to Enter Judgment of Non Pros

for Failure to File Written Statement from

an Appropriate Licensed Professional

To:

____________

(Identify Party)

Pursuant to Pennsylvania Rule of Civil Procedure 1042.12, I intend to enter a judgment of non pros against you after thirty (30) days of the date of the filing of this notice if a written statement from an appropriate licensed professional is not filed as required by Rule 1042.3(e).

I am serving this notice on behalf of

_________________________

(Name of party)

The judgment of non pros will be entered as to the following claims:

______________________________________

______________________________________

(State if a judgment is to be entered as to all claims. Otherwise, identify claims set forth in the complaint as to which a judgment of non pros will be entered.)

____________

(Attorney)

____________

(Address)

____________

(Telephone Number)