IN THE COUNTY COURT IN AND FOR HILL SBOROUGH COUNTY, FLORIDA CIVI L DIV ISI ON CASE NO. Plaintiff DIVISION Address (number) (street) (city) (state) (zip code) Phone: _________________________ vs Defendant Address (number) (street) (city) (state) (zip code) Phone: ST A T E M E NT OF CL A IM (Auto Negligence) Plaintiff ________________________, sues Defendant ________________________________________, and alleges: 1. This is an action for damages which does not exceed $5,000.00. 2. On or about __________________________,_______, in the vicinity of _______________________________ , on a public highway in _______________________County, Florida, Plaintiffs motor vehicle, being operated by _______________, and being owned by ______________________________________collided with Defendants motor vehicle being operated by ________________________________________________and being owned by _________________________. 3. The collision with Plaintiffs vehicle was caused by the negligent and careless operation of Defendants vehicle, whereby Plaintiffs vehicle was damaged and depreciated in value. WHEREFORE , Plaintiff demands judgment for damages against defendant in the sum of $_______________plus costs of this action. ____________________________________________ being first duly sworn on oath, says the foregoing is a just and true statement of the amount owing by Defendant to Plaintiff, exclusive of all set-offs and just grounds of defense. _____________________________ Plaintiff American LegalNet, Inc.COCV1251 (Rev. 01-04-05) www.USCourtForms.comPage 1 of 2>>>> 2STATE 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 ___________________________ Typed or Printed Name American LegalNet, Inc.COCV1251 (Rev. 01-04-05) www.USCourtForms.comPage 2 of 2