IN THE COUNTY COURT IN AND FOR DESOTO COUNTY, FLORIDA ________________________________ ________________________________ ________________________________ (Name and Address) Plaintiff(s), vs. ________________________________ ________________________________ ________________________________ (Name and Address) Defendant(s). ______________________________________/ CASE NO. ___________________ STATEMENT OF CLAIM (Civil Case $5,000.00 or less) The Plaintiff(s) sues Defendant(s) and alleges: This is an action for damages within the jurisdiction of this Court which do not exceed the amount of $5,000.00, not including costs, interest and attorney's fees. Plaintiff(s) claims the amount of $_______________ as being due from Defendant(s) and alleges as the basis of such suit: (check one only) ___ Goods, wares and merchandise sold by Plaintiff to Defendant; ___ Defective goods, workmanship, services furnished to Plaintiff by Defendant (List goods and describe defects below); ___ Work done and materials furnished by Plaintiff for Defendant; ___ Money lent by Plaintiff to Defendant which is due and payable; ___ Money due to Plaintiff upon accounts stated and agreed to between them; ___ Money received by Defendant for use of Plaintiff; ___ On a written instrument, copy of which is attached hereto; ___ Rent for certain premises in DeSoto County, Florida (copy of written lease attached/ address of premises listed below) ___ Auto negligence by Defendant causing damage to Plaintiff's vehicle (Describe below Defendant's negligent act which caused damage); ___ Other (Explain) ADDITIONAL FACTS ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Rev. 1/6/2010 American LegalNet, Inc. www.FormsWorkFlow.com Wherefore, Plaintiff(s) demand(s) judgment in the sum of $__________________, plus interest in the amount of $____________, together with court costs, attorneys fees and any further costs which the Court may assess. STATE OF FLORIDA, COUNTY OF ________________. The undersigned, being by me first duly sworn, says that: the foregoing is a just and true statement of the amount owing by the above named Defendant(s) to said Plaintiff(s), exclusive of all set-offs and just grounds for defense. Plaintiff(s) state(s) that the suit initiated by the foregoing Statement of Claim is brought in good faith and with no intention to annoy the above named Defendant(s). _________________________________________ Signature _________________________________________ Printed name of Plaintiff/Attorney _________________________________________ _________________________________________ Address Phone: ___________________________________ Sworn to and subscribed before me by ______________________________________________, who is personally know to me or produced __________________________________________________ as identification this ____ day of ___________________, 20____. __________________________________________ Deputy Clerk or Notary Public Rev. 1/6/2010 American LegalNet, Inc. www.FormsWorkFlow.com