Statement Of Claim (Small Claims) Form. This is a Florida form and can be use in Bay Local County.
Tags: Statement Of Claim (Small Claims), A, Florida Local County, Bay
COUNTY COURT, BAY COUNTY, FLORIDA SMALL CLAIMS DIVISION STATEMENT OF CLAIM PLAINTIFF(S): _________________________ DEFENDANT(S) ___________________________ _________________________ ___________________________ ADDRESS: _________________________ ADDRESS: _________________________ TELEPHONE: _________________________ ___________________________ ___________________________ TELEPHONE: __________________________ THIS IS A CIVIL ACTION THAT DOES NOT EXCEED $5000.00 PLAINTIFF CLAIMS THE AMOUNT OF $___________________ AS BEING DUE FROM THE DEFENDANT(S). TOGETHER WITH INTEREST OF $ ________________ ATTORNEY’S FEES OF $ ________________ PLUS COURT COST OF $ ________________ WHICH ALL TOTALS $ ________________ AND ALLEGES THAT THE BASIS OF THIS SUIT IS: Money due plaintiff on account. (See attached copy of accounts). Goods, wares, and merchandise sold by plaintiff to defendant. (List of goods and prices below). Money loaned by plaintiff to defendant. (Copy of any promissory note attached). Rent due plaintiff for certain premises. (List below: (1) address of premises and (2) amount and date of rent past due and attach copy of any written lease). Defective goods/workmanship/services furnished by defendant. (List time, materials, and charges below). Money due plaintiff for labor and materials furnished by defendant. (List time, materials, and charges below). FORM A Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Money due plaintiff for worthless check given by defendant. (See attached copy of check). Damages due to an auto collision. (Describe below: (1) defendant’s negligent act which caused collision and (2) nature and amount of your damages). Damages due to breach of contract or an implied/express warranty by defendant. OTHER: (Describe below: the nature of the contract and the breach). ADDITIONAL INFORMATION: STATE OF FLORIDA COUNTY OF BAY THE PLAINTIFF IN THE ABOVE STYLED CAUSE, UPON OATH DEPOSES AND SAYS THAT THE FOREGOING IS A JUST AND TRUE STATEMENT OF THE AMOUNT OWING BY THE DEFENDANT TO SAID PLAINTIFF EXCLUSIVE OF ALL SET – OFFS AND JUST GROUNDS OF DEFENSE; AND THIS SUIT IS BROUGHT IN GOOD FAITH, WITH NO INTENT TO ANNOY THE DEFENDANT. PLAINTIFF FURTHER STATES THAT THE DEFENDANT (IS) (IS NOT) IN THE MILITARY SERVICE. ______________________________________ __________________________________ PLAINTIFF PLAINTIFF SWORN TO AND SUBSCRIBED BEFORE ME THIS _________ DAY OF __________________, 20 _______. BILL KINSAUL CLERK OF COUNTY COURT SMALL CLAIMS DIVISION By: _____________________________________ Deputy Clerk or Notary Public I do certify that a copy has been furnished to the plaintiff by mail/hand on this _________ day of ______________, 20_______. FORM A Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com