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 The Plaintiff(s) sues the Defendant(s) and alleges: 1. This is an action for damages which does not exceed the sum of 2,500/5,000, exclusive of interest and costs. 2. On or about __________________________________________Defendant vacated the premises known as _____________________________________ Jacksonville, Duval County, Florida, being rented by Plaintiff and Defendant at a monthly rental rate of $__________________________ thereby breaking the least agreement attached hereto. 3. Upon vacating said premises without proper notice, Defendant left rents due and owing in the amount of $_________________ representing ____________________________________________________________. 4. Therefore, Plaintiff is seeking to recover monies due for Defendant's portion of the rent. 5. Plaintiff seeks to recover the additional amount of $___________________ representing Defendant's portion of _____________. WHEREFORE Plaintiff demands judgment in the sum of _______________ plus court costs. _______________________________________ (Signature) American LegalNet, Inc. www.FormsWorkFlow.com