IN THE COUNTY COURT OF THE EIGHTH JUDICIAL CIRCUIT, IN AND FOR ALACHUA COUNTY, FLORIDA 201 East University Avenue - Post Office Box 600 Gainesville Florida 32602 (352) 374-3636 Case No.: PLAINTIFF Division: Address City, State Zip Code Phone Phone -vs- DEFENDANT DEFENDANT Address Address City, State Zip Code City, State Zip Code Phone Phone STATEMENT CLAIM (Check) Plaintiff(s), , sue(s) Defendant(s), and alleges: 1. This is an action for damages which do not exceed the sum of $5,000.00, exclusive of costs, interest and attorneys fees. 2. On , , defendant(s) executed a written order for the payment of $ , commonly called a check, a copy being attached, payable to the order of plaintiff(s) and delivered it to plaintiff. 3. The check was presented for payment to the drawee bank but payment was refused. 4. Plaintiff holds the check and it has not been paid. 5. Defendant owes plaintiff $ that is due with interest from , on the check. OPTIONAL: Before filing suit, Plaintiff(s) delivered to Defendant(s) by certified or registered mail a written demand for payment of the check pursuant to Section 68.065, Florida Statutes, 30 days have elapsed since Defendant(s) received the demand and Plaintiff(s) has not been paid in full. A copy of the notice and a copy of the return receipt are attached. Plaintiff(s) is entitled to recover three times the amount of the check, but in no case less than $50.00, in addition to the amount of the check, plus court costs, reasonable attorneys fees and any bank fees incurred. WHEREFORE, Plaintiff(s) demands judgment for damages against defendant(s) in the amount of $ principal, plus $ interest, plus $ service charge, plus $ court costs. PLAINTIFF(S) STATEMENT OF CLAIM - CHECK.DOC, rev.January 9, 2003