IN THE COUNTY COURT IN AND FOR DUVAL COUNTY, FLORIDA CASE NUMBER: DIVISION: Name:__________________________________ Address:________________________________ Telephone:______________________________, Plaintiff VS. Name:__________________________________ Address:_________________________________ Telephone: ______________________________, Defendant Statement of Claim (Auto Accident) The Plaintiff sues the Defendant and says: On or about _______________________________________, in the vicinity of ________________________________________________________________________________, on a public highway in Duval County Florida, Plaintiffs motor vehicle, being operated by __________________ _________________, collided with the Defendant's motor vehicle, being operated by ____________________ _______________________________________ and the collision with the Plaintiff's vehicle was caused by the negligent and careless operation of Defendant's vehicle, whereby Plaintiff's vehicle was damaged and depreciated in value. WHEREFORE, Plaintiff demands judgment in the sum of $_____________ plus court costs. ____________________________ (Print name) ____________________________ (Signature) American LegalNet, Inc. www.FormsWorkFlow.com