IN THE COUNTY COURT IN AND FOR BAY COUNTY, FLORIDA _________________________________ Plaintiff / Landlord Vs Case no. ________________ Division ________________ _________________________________ Defendant / Tenant AFFIDAVIT OF DAMAGES State of Florida County of Bay 1. Before me, the undersigned authority, personally appeared ______________________________, who being first duly sworn, states as follows: 2. This affidavit is based on my own personal knowledge. 3. Defendant has possession of the property which is the subject of this eviction under an agreement to pay rent in the amount of $___________. 4. Defendant has not paid rent due since ______________________________. 5. Defendant owes Plaintiff $______________ (past due rent amount) as alleged in the complaint, $_________ in late fees, $______________ in court costs plus interest. 6. Defendant owes Plaintiff $________________(amount of other damages) as alleged in the complaint plus interest. Dated: ________________________ _______________________________________ Signature of Landlord _______________________________________ Address _______________________________________ City, State and Zip Code _______________________________________ Phone number Sworn and subscribed before me this ____ day of ______, 20___, by ____________________________, who is personally known to me or who has produced _______________________________ as identification and took and oath. ____________________________________ Deputy Clerk or Notary Public Form 13 American LegalNet, Inc. www.FormsWorkFlow.com