In the County Court in and for Manatee County, Florida ______________________________________________ Case No.___________________________ Plaintiff(s) Name ______________________________________________ Address ______________________________________________ City, State, Zip Code ______________________________________________ Telephone Number vs ______________________________________________ Defendant(s) Name ______________________________________________ Address ______________________________________________ City, State, Zip Code ______________________________________________ Telephone Number Auto Negligence Statement of Claim This claim does not exceed the amount of $5,000.00, exclusive of costs, interest and attorneys fees. The Plaintiff(s) sues the Defendant(s) and says: On or about the date of (month/day/year) __________________________ in the vicinity of __________________________________________________________ on a public h ighway in Manatee County, Florida, Plaintiffs mocle, being operator vehi ted by______________________________________ was in collision with defendants motor vehicle being operated by _________________________________________________________ and that said 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 in the sum of $________________________ plus all costs of this action. __________________________________________ Plaintiffs Signature autoneg