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 (Co-Signer) 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. That on or about _______________________________ , the Defendant did execute a loan in the amount of _________________________. The Plaintiff was co-maker on said loan and when the Defendant defaulted in the payments on said loan the Plaintiff was obligate to pay, as evidence per the attached. 3. Therefore, Plaintiff seeks to recover from the Defendant monies in the amount of $___________________, to cover the portion of the loan paid by the Plaintiff. WHEREFORE Plaintiff demands judgment in the sum of $ _____________ plus court costs. __________________________ (Print name) __________________________ (Signature) American LegalNet, Inc. www.FormsWorkFlow.com