COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.CLOCK ININ THE COUNTY COURT IN AND FOR BROWARD COUNTY FLORIDACalendar No.DIVISION:[ ] CIVIL [ ] OTHERSTATEMENT OF CLAIMJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)PLAINTIFF (S)vs.DEFENDANT (S)CASE NUMBERSPDIV:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The Plaintiff sues the Defendant for money owed Plaintiff by Defendant; and which is past due and unpaid; for (As marked (x) below) :THE PEOPLE OF THE STATE OF NEW YORK TO[ ] Goods, wares and merchandise sold by Plaintiff, to Defendant; [ ]Work done and materials furnished by Plaintiff, to Defendant; [ ]Money loaned by Plaintiff to Defendant; [ ]Money due to Plaintiff upon accounts stated and agreed to between them; [ ]On a written instrument, copy of which is attached hereto; [ ]Rent for certain premises in Broward County, Florida, Viz; [ ]Other (Explain) [ ]GREETINGS:Any additional facts in connection with any of the above: (Use additional sheet if necessary)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day ofnoon, and at any recessed in room, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of theYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,Where Plaintiff demands judgment in the sum of $ together with court costs which the court may assess. The Plaintiff, says the foregoing is a just and true statement of the amount owing by the Defendant to Plaintiff, exclusive of all set-offs and just grounds of defense. Affiant states that the Defendant(s) is/are not in the military service of the United States. SWORN AND SUBSCRIBED BEFORE ME this day of , 20 .PLAINTIFF OR ATTORNEYHOWARD C. FORMAN, CLERK OF COURTS(Attorney must sign above and type name below)ADDRESS OF PLAINTIFF/ATTORNEY Attorney(s) forby:DEPUTY CLERKNOTARY PUBLICOffice and P.O. AddressPLAINTIFF/ATTORNEY TELEPHONEState of FloridaTelephone No.: Facsimile No.: E-Mail Address:MY COMMISSION EXPIRES:()Mobile Tel. No.:COPY FEE : 699SEARCH FEE : 698ATTORNEY BAR NUMBER: FORM 633 REVISED 1/03American LegalNet, Inc. www.USCourtForms.com