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 Statement of Claim The above named Plaintiff(s) sues the above named Defendant(s) and alleges: 1. This is an action for damages which does not exceed the sum of $5,000.00 exclusive of costs, interest and attorneys fees. Said Plaintiff(s) claim the amount of $ _____________as being due from said Defendant(s) and alleges as the basis of such suit: Wherefore, Plaintiff(s) demands Judgment for damages against Defendant(s) in the amount of $_______________ , plus all costs of this action. ___________________________ Plaintiffs Signature claimstt.wpf