IN THE COUNTY COURT IN AND FOR HILLSBOROUGH COUNTY, FLORIDA CIVIL DIVISION CASE NO. Plaintiff A ddress DIVIS ION (Number) (Street) (City) (State) (Zip Code) Phone: vs Defendant A ddress (Number) (Street) (City) (State) (Zip Code) Phone: ST ATE M EN T OF CLA IM Plaintiff sues defendant and alleges:1. T his is an action for damages which does not exceed $ 5,000.00. 2. Plaintiff(s) claim the amount of $ as being due from said defendant(s) and alleges as the basis of such suit 3. Demand has been made for payment of said amount due, but defendant(s) has not paid plaintiff. W HERE FORE , plaintiff demands judgment in the amount of $ , plus all costs of this action.STATE OF FLORI DA COUNTY OF HILLSB ORO UGH being first duly sworn on oath, says the foregoing is a just and true statement of the amountowing by defendant to plaintiff, exclusive of all set-offs and just grounds of defense. Plaintiff or Agent COCV 1297(Rev.01-04-2005) Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com>>>> 2S T AT E OF F L ORI DA COUNTY OF HI L L SBORO UGH 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. PA T FRANK A s Clerk of the Court As Deputy Clerk Notary Public T yped or Printed Name COCV1297(Rev.01-04-2005) Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com