COUNTY COURT, BAY COUNTY, FLORIDA SMALL CLAIMS DIVISION STATEMENT OF CLAIM PLAINTIFF(S): DEFENDANT(S) ADDRESS: ADDRESS: TELEPHONE: TELEPHONE: EMAIL ADDRESS: 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 $ ATTORNEY222S FEES OF $ PLUS COURT COST OF $ WHICH ALL TOTALS $ AND ALLEGES THAT THE BASIS OF THIS SUIT IS: [Check or Circle the appropriate statement] 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) defendant222s 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: WHEREFORE, Plaintiff demands judgment against the Defendant(s) for damages in the amount claimed, costs, and any other relief that this Court deems just and proper. DATE: DATE: PLAINTIFF signature PLAINTIFF signature FORM A Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com