IN THE COUNTY COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA CASE NUMBER: 05 DIVISION: SMALL CLAIMS PLAINTIFF ________________________________________ DEFENDANT ________________________________________ ________________________________________ - SC -XXXX-XX CLOCK IN STATEMENT OF CLAIM (Summary Claims) PLAINTIFF'S ADDRESS & PHONE NUMBER ____________________________________ ____________________________________ ____________________________________ DEFENDANT'S ADDRESS(ES) & PHONE NUMBER(S) ____________________________________ ____________________________________ ____________________________________ together with costs and attorney's fees, if The Plaintiff claims the amount of $ applicable, as being due from the defendant and alleges as the basis of such suit the following matters: (Fill in the appropriate blanks) Goods sold and delivered by Plaintiff(s) to Defendant(s) between __________________, 20_____, and __________________, 20____. Labor and materials furnished by Plaintiff(s) to Defendants(s) between __________________, 20_____, and __________________, 20____. Money lent by Plaintiff(s) to Defendant(s) on or about __________________, 20_____, with interest from __________________, 20____, in the amount of $_____________. Law 167 / Rev. 10-07-2015 1 American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER: 05- -SC- -XXXX-XX On _______________, 20____, Defendant(s) executed and delivered to Plaintiff(s) a promissory note in ___________________ County, Florida. Defendant(s) failed to pay box said note when due, the installment payment due on said note on _______________, 20____, and Plaintiff(s) elected to accelerate payment of the balance. The balance now due, owing and unpaid is $_____________ plus interest since _______________, 20____, in the amount of $_____________. On or about __________________, 20_____, in the vicinity of __________________ on a public highway in _______________________ County, Florida, Plaintiff's motor vehicle being operated by ___________________________ was in collision with Defendant's motor vehicle being operated by ___________________________, and that said collision with Plaintiff's vehicle was caused by the negligent and careless operation of Defendant's vehicle, whereby Plaintiff's vehicle was damaged and depreciated in value. Plaintiff(s) and Defendant(s) entered into a verbal/written rental agreement on __________________, 20_____, for the property located at _______________________, Brevard County, Florida. Defendant(s) vacated said property on or about __________________, 20_____. Plaintiff is entitled to $_____________ which represents: [a] Rent due from __________________, 20_____ to __________________, 20____. [b] Damages to said property in the amount of $_____________. [c] Damage Deposit which Defendant failed to return. Plaintiff is filing complaint pursuant to F.S. 713.78(5)(a), to determine if property was wrongfully taken or withheld. Plaintiff has also posted a cash bond in the amount of $_____________, pursuant to F.S. 713.78(5)(b), in the amount equal to the lien claimed. _______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ WHEREFORE, Plaintiff demands judgment in the amount of $_______________, plus interest in the amount of $_______________, and applicable court costs and attorney's fees. Law 167 / Rev. 10-07-2015 2 American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER: 05STATE OF FLORIDA - COUNTY OF BREVARD -SC- -XXXX-XX ___________________________________ being duly sworn on oath states the foregoing claim is a just and true statement of the amount owing by the defendant to the Plaintiff, exclusive of all set-offs and just grounds of defense. Plaintiff states that the Defendant(s) are not in the Military Service of the United States and that the above action has been brought in the County of proper venue. Dated this _______ day of __________________, 20_____ _________________________________________________ PLAINTIFF, ATTORNEY, OR CORPORATE AGENT SWORN AND SUBSCRIBED TO BEFORE ME THIS __________ DAY OF _______________, 20 _____. __________________________________ DEPUTY CLERK STATE OF FLORIDA BREVARD COUNTY, FLORIDA THE FOREGOING INSTRUMENT WAS ACKNOWLEDGED BEFORE ME THIS THIS __________ DAY OF _______________, 20 _____, BY ________________________________________________________, WHO IS PERSONALLY KNOWN TO ME OR HAS PRODUCED ________________________________________________________________ AS IDENTIFICATION AND WHO DID (DID NOT) TAKE AN OATH. _____________________________________ NOTARY PUBLIC Law 167 / Rev. 10-07-2015 3 American LegalNet, Inc. www.FormsWorkFlow.com