SMALL CLAIMS WORKSHEET Plaintiff"s Statement (person or business filing claim) Name: _______________________________________________ PLEASE PRINT OR TYPE Phone: _______________________ Address: _________________________________________________________________________________ Amount of Claim $____________________________ DO NOT ADD COSTS OF FILING THIS ACTION This claim is for: CHECK THE SENTENCE THAT BEST DESCRIBES YOUR CLAIM Goods, wares and merchandise sold by Plaintiff to Defendant Work done and materials furnished by Plaintiff to Defendant Money loaned by Plaintiff to Defendant Money on a written instrument, copy of which is attached hereto Rent for certain premises in Hernando County, Florida Other (Briefly describe claim) ___________________________________________________________ Date and Place alleged Claim was incurred ______________________________________________________ If the Defendant is an individual, is he/she in the military service? YES If not, are you prepared to swear under oath to this fact? YES PLEASE NOTE: (A) (B) (C) (D) If you are claiming against an individual, give his or her full name. If you are claiming against a business/firm, give the name of the owner and the name of the business. If you are claiming against a corporation, give the full corporation name and officer or registered agents name for service. If your claim arises as a result of an automobile accident, you may name the driver and also the registered owner of the vehicle. NO NO My Claim is Against: (1) __________________________________________ NAME __________________________________________ ADDRESS __________________________________________ CITY, STATE ZIP CODE (2) __________________________________________ NAME __________________________________________ ADDRESS __________________________________________ CITY, STATE ZIP CODE (3) __________________________________________ NAME __________________________________________ ADDRESS __________________________________________ CITY, STATE ZIP CODE (4) __________________________________________ NAME __________________________________________ ADDRESS __________________________________________ CITY, STATE ZIP CODE Phone Number of Defendant: _________________ SMALL_CLAIMS_WKSHT_12122014 _____________________________________________ Plaintiff or Agent for Plaintiff (please sign before filing) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR SMALL CLAIMS WORKSHEET (Use for claims up to $5,000.00 only) *Please do not include the instruction sheets when submitting your worksheet PLAINTIFF INFO (Party Filing Suit) Under Plaintiff's Statement, please PRINT OR TYPE your name (this may be an individual, company, business or corporate name) and complete address. Also, provide a phone number where you can be reached. HOW DID YOUR CLAIM COME ABOUT? On the lines provided, fill in the amount for which you are claiming and check the line that best describes your claim. Be sure NOT TO ADD COURT COSTS to the amount for which you are claiming. The clerk will add the court costs to the total, if claim is filed in person. If you don't feel that the sentences provided describe your particular situation, check OTHER and write a brief description. You should also provide the date and place where the alleged claim occurred. MILITARY SERVICE Regarding military service, the question, "Is he/she in the military service?" MUST be answered to the best of your ability. The Soldiers and Sailors Civil Relief Act of 1940 states that proceedings may be stayed at any stage, at the discretion of the Court, so that military personnel would not be subject to prosecution while unable to attend court proceedings. The Soldiers and Sailors Civil Relief Act, states that, "any person who shall make or use an affidavit required under this section, or a statement, declaration, verification or certificate, certified or declared to be true under penalty of perjury, knowing it to be false, shall be guilty of a misdemeanor and shall be punishable by imprisonment not to exceed one year or by fine not to exceed $1,000.00 or both." NAMING YOUR DEFENDANT(S) Under "My Claim is Against", PRINT OR TYPE the name of the person you wish to sue. If the Defendant is a corporation, we must have the name of the President, Vice President or Registered Agent on which to serve the papers, indicating name and title. You may obtain this information on the internet at www.sunbiz.org. You must also PRINT OR TYPE the defendants address or address at which service can be satisfied. SMALL_CLAIMS_WKSHT_12122014 American LegalNet, Inc. www.FormsWorkFlow.com