Pa.R.Civ.P. 1042.11. — Notice of Intent to Enter Judgment of Non Pros for Failure to File a Written Statement from an Appropriate Licensed Professional. Form of Notice.

(a) A defendant seeking to enter a judgment of non pros under Rule 1042.12 shall file a notice of intent to enter a judgment of non pros for failure to file a written statement from an appropriate licensed professional with the certificate of merit.

(b) The notice required by subdivision (a) of this rule shall be substantially in the following form: (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)