IN THE COUNTY COURT OF THE FIFTH JUDICIAL CIRCUIT IN AND FOR HERNANDO COUNTY, FLORIDA CASE NO.: __________________________________ ____________________________________ , Plaintiff(s) _____________________________________________ _____________________________________________ Address -VS- ____________________________________ , Defendant(s) _____________________________________________ _____________________________________________ Address STATEMENT OF CLAIM The Plaintiff(s) sue(s) the Defendant(s) and states: AMOUNT OF CLAIM: _________________ FILING FEE: SHERIFF FEE: TOTAL: This is an action for damages less than $5,000.00 exclusive of costs, interest and attorney's fees. The undersigned, being by me first duly sworn, says that he/she is the Plaintiff(s), Agent for Plaintiff(s), or Attorney for Plaintiff(s) and that the foregoing is a just and true statement of the amount owed by the above named Defendant(s) to said Plaintiff(s), exclusive of all set offs and just grounds for defense. Plaintiff(s) state(s) that the suit initiated by the foregoing statement of claim is brought in good faith and with no intention to annoy the above named Defendant(s); and, further says that the Defendant(s) is/are not in the military service of the United States. Wherefore, Plaintiff(s) demand(s) judgment for damages against the Defendant(s). Subscribed and sworn to before me this __________day of ____________________, ______. _____________________________________________ Signature _________________ _________________ _________________ ____________________________________________ Deputy Clerk or Notary Public if signed outside of Clerk's office DON BARBEE, JR. Clerk of County Court Hernando County 20 N. Main Street, Room 248 Brooksville, FL 34601 American LegalNet, Inc. www.FormsWorkFlow.com SMALL_CLAIMS_STATEMENT_CLAIM 12122014