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) sue 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. On or about ____________________________________________ , Defendant vacated the premises more commonly known as ___________________________________ , Jacksonville, Duval county, Florida, being rented by the defendant at a monthly rental rate of $ _________________________________ , as per copy of rental agreement attached hereto. 3. Upon vacating said premises, Defendant left monies due and owing in the amount of $_________________________ as rents for _________________________________________ to ____________________________________________. 4. Therefore, Plaintiff is seeking to recover monies due for rent of said premises in the sum of $___________________. 5. That during said tenancy of the Defendant certain damages were noted by the Plaintiff upon Defendant's vacating the premises. Plaintiff is seeking to recover from the Defendants monies in the amount of $________________ , which represents the damages to wit. WHEREFORE Plaintiff demands judgment In the sum of ___________________ plus interest and costs. ______ _______________________ (Signature) American LegalNet, Inc. www.FormsWorkFlow.com