IN THE COU NTY COU RT IN AND FOR HIL L SBO ROU GH COU NTY, FL ORI DA CIVIL DIVISI ON *CA SE NO. *DIV IS ION Plaintiff/Landlord vs * * * Defendant/T enant AFFIDAV IT IN PROOF OF LA NDLORDS CL AIM FOR PAS T DUE RENT COUNT II S T AT E OF F L ORI DA C OU NT Y OF HIL L S BOR OU GH Before me, the undersigned authority, personally appeared , who duly sworn, deposes and says: 1. T hat he/she is the [ ]owner [ ] landlord of the property involved in this lawsuit, and that the defendant(s) defaultedin the lease agreement by failing to make rental payments. 2. The rent was $ per [ ] week, [ ] month, [ ] other. (amount) 3. Defendant(s) owe/owes $ to Plaintiff, for the period of to based on full [ ] weeks, [ ] months and days at $ (number) (number) (pro-rated) per day, plus late char ges, if any, of $ per day for days, based upon the written lease agreement. 4. Plaintiff holds a security deposit from the defendant in the amount of $ . TH E BA LA NC E DUE I S: AM OUNT OW ED $ A M OUNT C R ED I TE D $ NET BA LA NC E OW ED $ F urther aff iant sayeth Not. Name: T itle: S T AT E OF F L ORI DA C OU NT Y OF HI L L S BOR OU GH T he 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. P A T FR A NK As Clerk of the Court As Deputy Clerk Notary Public Ty ped or Pr inted Name COCV1245(Rev.1/4/2005) American LegalNet, Inc. www.USCourtForms.com