IN THE COUNTY COURT IN AND FOR CHARLOTTE COUNTY, FLORIDA SMALL CLAIMS DIVISION (Please type or print using a ballpoint pen.) ________________________________________ ________________________________________ Case No. ______________________ Refer to this No. in making any inquiries. ________________________________________ Plaintiff VS. DEFENDANT(S) TO BE SERVED AT: ___________________________________________ _________________________________________ ___________________________________________ _________________________________________ ___________________________________________ _________________________________________ Defendant STATEMENT OF CLAIM Plaintiff,________________________________________________________________________________________ sues Defendant, _________________________________________________________________________________________ and alleges: 1. 2. This is an action for damages which does not exceed $5,000.00 exclusive of costs, interest, and attorney’s fees. There is now due, owing and unpaid from defendant to plaintiff $________________________________ with interest (circle if applicable) for the following reasons: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ WHEREFORE, Plaintiff demands judgment against Defendant for damages and costs of this action. _____________________________________ Plaintiff’s Signature _____________________________________ Address _____________________________________ City, State and Zip Code (______)______________________________ Telephone Number ______________________________________ Attorney Signature ______________________________________ Address ______________________________________ City, State and Zip Code (______)_______________________________ Telephone Number American LegalNet, Inc. www.FormsWorkflow.com