IN THE COUTY COURT IN AND FOR DUVAL COUNTY FLORIDA CASE NUMBER: DIVISION: __________________________________ (Plaintiff) VS. __________________________________ (Defendant) PROOF OF CLAIM (REPLEVIN) STATE OF FLORIDA COUNTY OF DUVAL Before me, the undersigned authority, personally appeared __________________________________________ _______________________________________ who being first duly sworn, deposes and says; the he (she) (they) is (are) the Plaintiff(s)or Plaintiff's agent named in the Statement of Claim filed herein; that the balance due to Plaintiff(s) from the Defendant(s) is the sum of $_____________________, plus court costs, which is a true and correct statement of the account as of __________________________________________________________ and that no set-offs exist. This action has been brought in Duval County where venue is proper. At Jacksonville, Florida this ____________ day of ____________,______________. Further that the Plaintiff(s) is (are) entitled to possession of the personal property which is the subject of this suit; that the Plaintiff(s) has (have) made demand upon Defendant(s) for possession of said personal property, but Defendant(s) refuses to surrender possession to the Plaintiff(s), and wrongfully retains possession of said property; This action has been brought in Duval County where venue is proper. At Jacksonville, Florida this _____________day of __________,____________. _________________________________ (Signature) SWORN TO AND SUBSCRIBED BEFORE ME THIS _______ DAY OF ________ , ______. RONNIE FUSSELL, CLERK OF THE CIRCUIT AND COUNTY COURTS DUVAL COUNTY, FLORIDA BY:___________________________________ Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com