IN THE COUNTY COURT, FIFTH JUDICIAL CIRCUIT IN AND FOR CITRUS COUNTY, FLORIDA CASE NO: Plaintiff(s) -VS- Defendant(s) ________________________________/ FACT INFORMATION SHEET - INDIVIDUAL Full Legal Name: ________________________________________ Nicknames or Aliases: ____________________________________ Residence Address: ____________________________________________________________________________ Street City State Zip Code Mailing Address (if different): ____________________________________________________________ Street City State Zip Code Telephone Numbers: (Home) ______________________ (Business) __________________________ Name of Employer: ______________________________ Position or Job Description: _____________ Address of Employer: _________________________________________________________________ Street City State Zip Code Rate of Pay: $ _____________ per __________ Average Paycheck: $ ______________ per ________ Average Commissions or Bonuses: $ ____________ per __________ Commissions or bonuses are based on ____________________________________________________________________________ Other Personal Income: $ _________________________ from _________________________________ (Explain details on the back of this sheet or an additional sheet if necessary.) Social Security Number: ________________________________ Birthdate: ______________________ Driver's License Number: _________________________________ Marital Status: ________________ Spouse's Name: _________________________________________ C:COUNTY/FORMS/JUDGMENTS/Fact Information Sheet/12/2002/updated American LegalNet, Inc. www.FormsWorkFlow.com Spouse's Address (if different): __________________________________________________________ Street City State Zip Code Spouse's Social Security Number: ___________________________ Birthdate: ___________________ Spouse's Employer: ___________________________________________________________________ Spouse's Average Paycheck or Income: $ ______________________________ per ________________ Other Family Income: $ _____________________________________________ per _______________ (Explain details on back of this sheet or an additional sheet if necessary.) Name and Ages of All Your Children (and addresses if not living with you): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Child Support or Alimony Paid: $ ______________________________ per _______________________ Names of Others You Live With: _________________________________________________________ Who is Head of Your Household? ____ You ____ Spouse ____________________ Other (list name) Checking Account at: _______________________________________ Account # _________________ Savings Account at: ________________________________________ 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: ____________________________________________________________________________ Street City State Zip Code All Names on Title: ____________________________________________________________________ Mortgage Owed To: ___________________________________________________________________ Balance Owed: $_______________________________ Monthly Payment: $ _____________________ (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 #: ___________________ 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.) American LegalNet, Inc. www.FormsWorkFlow.com Have you given, sold, loaned, or transferred any real or personal property worth more than $100 to any person in the last year? If your answer is "yes", described 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 is owed: _______________________________________________________________ Please attach copies of the following: a. b. c. d. Your last pay stub. Your last 3 statements for each bank, savings, credit union, or other financial account. Your motor vehicle registrations and titles. Any deed 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 COMPLETE. ______________________________________ Judgment Debtor Date STATE OF FLORIDA COUNTY OF __________________________ 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; __________________ MAIL OR DELIVER THE COMPLETED FORM TO THE JUDGMENT CREDITOR OR THE CREDITOR'S ATTORNEY. THIS FORM IS NOT TO BE FILED WITH THE CLERK OF THE COURT. C:COUNTY/FORMS/JUDGMENTS/Fact Information Sheet/12/2002/updated 11/20/2015 American LegalNet, Inc. www.FormsWorkFlow.com