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: This is an action for damages which does not exceed the sum of $2,500/$5,000, exclusive of interest and costs. 1. Plaintiff is the owner of those certain premises more commonly known as ___________________________, Duval County, Florida. Plaintiff is seeking to recover monies due from the Defendant for the rental and use of the said premises. 2. There is now due and owing from the Defendant $_________________________ for a period covering ___________________ to ____________________ under an oral/written agreement to pay monthly rental of _________________________. Defendant vacated said premises on ______________________ leaving said rents due and owing. WHEREFORE Plaintiff demands judgment In the sum of ____________________ plus court costs. _________________________________ (Print name/ signature) American LegalNet, Inc. www.FormsWorkFlow.com