IN THE COUNTY COURT IN AND FOR DUVAL COUNTY, FLORIDA CASE NUMBER: DIVISION: Name:__________________________________ Address:________________________________ City, State: ______________________________ Telephone:______________________________ , Plaintiff VS. Name:_________________________________ Address:_______________________________ City, State:______________________________ Telephone:______________________________ , Defendant Statement of Claim (Money Lent) The Plaintiff(s) 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 $________________ for money lent by the Plaintiff to the Defendant on __________________________________________, with interest thereon since ____________________________________________________________________________________. WHEREFORE, Plaintiff demands judgment in the sum of $________________ plus interest and court costs. ___________________________ (Print name) ___________________________ (Signature) American LegalNet, Inc. www.FormsWorkFlow.com