IN THE COUNTY COURT IN AND FOR BAY COUNTY, FLORIDA ____________________________ Plaintiff/Landlord Case No. ______________ -vs___________________________ Defendant/Tenant AFFIDAVIT OF DAMAGES State of Florida County of Bay 1. 2. 3. Before me, the undersigned authority, personally appeared __________________________, who being first duly sworn, says: This affidavit is based on my own personal knowledge. Defendant has possession of the property which is the subject of this eviction under an agreement to pay rent of $____________. 4. 5. Defendant has not paid the rent due since ____________________. Defendant owes Plaintiff $___________________ (past due rent amount) as alleged in the complaint, $___________________ in late fees, $____________________ court costs plus interest. 6. Defendant owes Plaintiff $__________________ (amount of other damages) as alleged in the complaint plus interest. _________________________________ Signature of Landlord _________________________________ Address _________________( City, State, Zip Code )____________ Phone The foregoing instrument was acknowledged before me this ________ day of _______________, 20_______, by ________________________, who is personally known to me or who has produced _______________________________ as identification and who [ ] did [ ] did not take an oath. _______________________________ Deputy Clerk or Notary _________________________________ Print Name Form 3-n American LegalNet, Inc. www.FormsWorkFlow.com