1 o f 2 IN THE COUNTY COURT OF THE NINETEENTH JUDICIAL CIRCUIT IN AND FOR MARTIN COUNTY, FLORIDA CIVIL DIVISION CASE NO.: Plaintiff(s) JUDGE: Address (number) (street) Phone: (city) (state) (zip code) vs Defendant(s) Address (number) (street) Phone: (city) (state) (zip code) STATEMENT OF CLAIM The above named Plaintiff(s) sue(s) the above named Defendant(s) for (check one): Auto negligence. Money lent. Goods sold. Promissory note. Work done and materials furnished. Other. Please give a brief description on the lines below: Wherefore, Plaintiff(s) demand(s) judgment in the amount of $ plus court costs. American LegalNet, Inc. www.FormsWorkFlow.com 2 o f 2 STATE OF FLORIDA, COUNTY OF MARTIN: The undersigned says that he/she is the of/for the above named Plaintiff; that the foregoing is a just and true statement of the amount owing by the above named Defendant(s) to Plaintiff(s), exclusive of all set - offs and just grounds o f defense. Signature of Plaintiff or Agent The foregoing instrument was sworn to or affirmed and signed before me this day of , by who is p ersonally known to me or who has produced as identification and w ho did [ ] did not [ ] take an oath. CAROLYN TIMMANN Clerk of the Circuit Court & Comptroller BY: or Deputy Clerk Notary Public or Typed or Printed Name Typed or Printed Name American LegalNet, Inc. www.FormsWorkFlow.com