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 (Back Wages) The Plaintiff sues the Defendant(s) and alleges: 1. This is an action for damages which does not exceed the sum of $5,000, exclusive of interest and costs. 2. There is now due, owing and unpaid from the Defendant to the Plaintiff monies in the sum of $_________________________ , which represents ________________________________ pay for on or about _______________________________________ through ___________________________________________. 3. Although Plaintiff has made numerous demands to Defendant for payment, Defendant has failed and or refused to pay said monies. All as evidence by copies of exhibits attached hereto and made a part hereof. WHEREFORE Plaintiff demands judgment In the sum of $_____________________ Plus court costs. _____________________________ (Print name) _____________________________ (Signature) American LegalNet, Inc. www.FormsWorkFlow.com