IN THE COUNTY COURT OF THE SECOND JUDICIALCIRCUIT IN AND FOR LEON COUNTY, FLORIDA CASE NO. _______________________________ Plaintiff(s), vs. _______________________________ Defendant(s). AFFIDAVIT OF DAMAGES STATE OF FLORIDA, COUNTY OF LEON. BEFORE ME, the undersigned authority, personally appeared ____________________________________________________, who being first duly sworn, says: 1. 2. 3. I am the [ ] Plaintiff(s) or [ ] Plaintiff’s agent in this case and am authorized to make this statement. This statement is based on my own personal knowledge. Defendant(s) owes the Plaintiff(s) the following amounts for the following reasons: AMOUNTS REASONS $______________ _______________________________ $______________ _______________________________ $______________ _______________________________ $______________ _______________________________ $______________ _______________________________ TOTAL $______________ (attach additional page if necessary) Revised 11/6/2006 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Dated this _____ day of __________________, ______. ______________________________ __________________________________ (Signature) (Printed Name) 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. BOB INZER Clerk of Court, Leon County By:______________________________ Deputy Clerk/Notary _______________________________ (Printed Name) Revised 11/6/2006 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com