IN THE COUNTY COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA CASE NUMBER: 05 DIVISION: SMALL CLAIMS PLAINTIFF CLOCK IN -XXXX-XX DEFENDANT FACT INFORMATION SHEET ­ BUSINESS ENTITY NAME/Title of person filling out this form: ADDRESS HOME TELEPHONE NUMBER BUSINESS NUMBER ADDRESS OF BUSINESS ENTITY TYPE OF ENTITY (check one) CORPORATION PARTNERSHIP LIMITED PARTNERSHIP SOLE PROPRIETORSHIP LIMITED LIABILITY CORPORATION (LLC) PROFESSIONAL ASSOCIATION (PA) OTHER (Please Explain) Does Business Entity own/have interest in any other business entity? If so please explain: Gross/Taxable income reported for Federal Income Tax purpose last three years: $ $ $ TAXPAYER IDENTIFICATION NUMBER LIST PARTNERS (General or Limited and Designate Percentage of Ownership): AVERAGE NO. OF EMPLOYEES/MONTH: NAME OF OFFICES AND DIRECTORS: CHECKING ACCOUNT AT: ACCOUNT NO.: SAVINGS ACCOUNT AT: ACCOUNT NO.: DOES THE BUSINESS ENTITY OWN ANY VEHICLES: YEARS/MAKES/MODELS: VEHICLE I.D. NOS.: TAG NOS.: LOANS OUTSTANDING: Law 979 / Rev. 08-13-2015 1 American LegalNet, Inc. www.FormsWorkFlow.com PLAINTIFF DEFENDANT CASE NUMBER 05-XXXX-XX DOES THE BUSINESS ENTITY OWN ANY REAL PROPERTY: IF YES, ADDRESS: Please check if the business entity owns the following: BOAT STOCKS/BONDS OTHER PERSONAL PROPERTY YES NO CAMPER OTHER REAL PROPERTY INTANGIBLE PROPERTY UNDER PENALTY OF PERGURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE TRUE AND COMPLETE ________________________________ Defendant's Designated Representative ________________________________ Title State of Florida County of Brevard The foregoing instrument was acknowledged before me on ___________________, 20____, by ____________________________, who is personally known to me or has produced _____________________ as identification and who did did not take an oath. WITNESS my hand and official seal on ____________________, 20____. _____________________________________ Notary Public, State of Florida My Commission Expires: ___________________ MAIL OR DELIVER THIS FORM TO THE CLERK OF THE COURT, AND MAIL OR DELIVER A COPY OF THE COMPLETED FORM TO THE JUDGMENT CREDITOR OR THE CREDITOR'S ATTORNEY Law 979 / Rev. 08-13-2015 2 American LegalNet, Inc. www.FormsWorkFlow.com