1. (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.

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

   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.)

3. (Attorney) (Address) (Telephone Number)

(Caption)

Notice of Intention to Enter Judgment of Non Prosfor Failure to File Written Statement froman Appropriate Licensed Professional