IN THE COUNTY COURT IN AND FOR HILL SBOROUGH COUNTY, FLORIDA CI VIL DIV ISI ON * CASE NO. * DIVISION Plaintiff(s) vs * * Defendant(s) AF FIDAVIT IN PROOF OF CLAIM AND NON-MILITARY SE RVICE COUNT I (Tenant Eviction and/or Past Due Rents and Court Costs) STATE OF FLO RIDA COUNTY OF HILLSB OROUGH Before me, the undersigned authority, personally appeared , whoduly sworn, deposes and says: 1. That he/she is the Landlord of rented premises located in Hillsborough County, Florida, described as follows: 2. That Defendant(s), rented the subject premises from the L andlord agreeing to pay the rent of $ per [ ] week, [ ] month, [ ] other . 3. The Defendant(s) failed to pay the rent due on the day of , , whereupon the Landlord, on the day of , , served a three (3) day notice demanding payment of the rent or possession of the premises. 4. The Defendant(s) failed to comply with either of the demands of the notice within the applicable time period. 5. The Defendant(s) owe(s) the Landlord $ for past-due rents as of the date of this affidavit. 6. In addition, the Landlord has paid a filing fee in the amount of $__________ and a service of process fee in the amount of $__________. cocv1241(REV 1/4/2005) Page 1of 2>>>> 2 7. Therefore, as of the filing of this affidavit the Defendant(s) are indebted to Plaintiff for the total amount of $__________ which amount is comprised of past due rents and fees. 8. The Defendant(s) is/are not now nor has/have been in the military service of the United States of America since the institution of this action. _____________________________ L andlord STATE OF FLORIDA COUNTY OF HIL LS BOROUGH The foregoing instrument was acknowledged before me this____day of ____________________ ___________________,_____________,by ____________________________________ who is personally known to me or who has produced _____________________________________as identification and who did [ ] did not [ ] take an oath. Pat Frank As Clerk of the Court ___________________________ ______________________________ As Deputy Clerk Notary Public ______________________________ Type or Print Name COCV 1241(REV.1/4/2005) Page 2 of 2