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 ­ INDIVIDUAL SMALL CLAIMS RULES FORM 7.343 FULL LEGAL NAME NICK NAME OR ALIAS RESIDENCE ADDRESS MAILING ADDRESS HOME PHONE NUMBER BUSINESS PHONE NAME OF EMPLOYER ADDRESS OF EMPLOYER POSITION OR JOB DESCRIPTION RATE OF PAY: $ PER . AVERAGE PAYCHECK $ PER AVERAGE COMMISSIONS OR BONUS: $ PER . COMMISSIONS OR BONUSES ARE BASED ON . Explain details on the back OTHER PERSONAL INCOME $ FROM of this sheet or an additional sheet if necessary.) SOCIAL SECURITY NO. BIRTHDATE DRIVER LICENSE NO. MARITAL STATUS SPOUSE'S NAME SPOUSE'S ADDRESS (if different) SPOUSE'S S.S.N. BIRTHDATE SPOUSE'S EMPLOYER SPOUSE'S AVERAGE PAYCHECK OR INCOME: $ PER Law 390 / Rev. 08-06-2015 1 PLAINTIFF DEFENDANT CASE NUMBER 05-XXXX-XX OTHER FAMILY INCOME: $ PER (Explain details on back of this sheet or an additional sheet if necessary) NAMES AND AGES OF ALL YOUR CHILDREN (and addresses if not living with you): CHILD SUPPORT OR ALIMONY PAID: $ NAMES OF OTHERS YOU LIVE WITH: WHO IS HEAD OF YOUR HOUSEHOLD? CHECKING ACCOUNT AT: SAVINGS ACCOUNT AT: PER YOU SPOUSE OTHER PERSON ACCOUNT #: ACCOUNT #: Describe all other accounts or investments you may have, including stocks, mutual funds, savings bonds, or annuities, on the back of this sheet or an additional sheet if necessary. FOR REAL ESTATE (LAND) YOU OWN OR ARE BUYING: ADDRESS: ALL NAMES ON TITLE: MORTGAGE OWED TO: BALANCE OWED: MONTHLY PAYMENTS: Attach a copy of the deed or mortgage, or list the legal description of the property on the back of this sheet or an additional sheet if necessary. Also, provide the same information on any other property you own or are buying. FOR ALL MOTOR VEHICLES YOU OWN OR ARE BUYING: YEAR______ MAKE __________________MODEL_________________COLOR___________ VEHICLE ID #_______________________ TAG NO__________MILEAGE_______________ NAMES ON TITLE: _________________________________ PRESENT VALUE __________ LOAN OWED TO: _____________________________________________________________ BALANCE ON LOAN: $______________________ MONTHLY PAYMENT: $______________________ (List all other automobiles, as well as other vehicles, such as boats, motorcycles, bicycles, or aircraft, on the back of this sheet or an additional sheet if necessary.) Law 390 / Rev. 08-06-2015 2 American LegalNet, Inc. www.FormsWorkFlow.com PLAINTIFF DEFENDANT CASE NUMBER 05-XXXX-XX Have you given, sold, loaned, or transferred any real or personal property worth more than $100 to any person in the last year? If you answer "yes", describe the property and sale price, and give the name and address of the person who received the property. DOES ANYONE OWE YOU MONEY? _______ AMOUNT OWED: $________________ NAME AND ADDRESS OF PERSON OWING MONEY: ______________________________ ______________________________________________________________________________ REASON MONEY OWED: ______________________________________________________ Please attach copies of the following: a. Your last pay stub. b. Your last 3 statements for each bank, savings, credit union, or other financial account. c. Your motor vehicle registrations and titles d. Any deeds or titles to any real or personal property you own or are buying, or leases to property you are renting. Under penalty of perjury, I swear or affirm that the foregoing answers are true and correct. ______________________________ Judgment Debtor STATE OF FLORIDA COUNTY OF BREVARD The foregoing instrument was acknowledged before me this _______ day of _______________, 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, this ______ day of __________________, 20____. _______________________________________ NOTARY PUBLIC STATE OF FLORIDA My Commission Expires: Law 390 / Rev. 08-06-2015 3 American LegalNet, Inc. www.FormsWorkFlow.com