… IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT IN AND FOR MIAMI-DADE COUNTY, FLORIDA. … IN THE COUNTY COURT IN AND FOR MIAMI-DADE COUNTY, FLORIDA. CASE NUMBER DIVISION … CIVIL PLAINTIFF STATEMENT … DISTRICTS … OTHER PLAINTIFF(S) VS. (Person(s) filing the lawsuit) ADDRESS and PHONE NO.(s) DEFENDANT(S) (Person(s) the lawsuit is filed against) CLOCK IN ADDRESS and PHONE NO.(s) SEE REVERSE FOR IMPORTANT INSTRUCTIONS Date and Place alleged debt or contract was incurred or damage occurred. Date: _____________________ Location: ______________________________________________________________ Amount of Claim: $ _________________________. THIS CLAIM IS FOR: … Goods, wares and merchandise sold by Plaintiff to Defendant: … Work done and materials furnished by Plaintiff to Defendant: … Money loaned by Plaintiff to Defendant: … Money due to Plaintiff upon accounts stated and agreed to between them: … On a written instrument, copy of which is attached hereto; … Rent for certain premises in Miami-Dade County, Florida, VIZ; … Additional Facts: __________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _______________________________________ Signature of Plaintiff/or Agent HARVEY RUVIN CLERK OF COURTS CLK/CT. 150 Rev. 05/11 BY: ______________________________________ DEPUTY CLERK DATE Clerk’s web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com (A) Enter your Name, Business Firm, or Corporation Names(s), along with your address and home number in the spaces provided. IF YOU ARE SUING: (B) An individual, give his/her full name address in the space provided above. (C) A Business Firm, give the Firm Name and the Name of the Owner and Addresses of each in the spaces provided. (D) A Partnership, you must name all of the Partners and their addresses in the spaces provided. (E) A Corporation, give it’s Full Name, state where incorporated, and the names and addresses of its Officers in the spaces provided. (F) If your suit arises as a result of an automobile accident, you may name the driver, and also the registered owner of the vehicle along with their address in the space provided. (G) If you are unable to determine which of the above applies to your case, please see the clerk. AMERICANS WITH DISABILITIES ACT OF 1990 ADA NOTICE “If you are a person with a disability who needs any accommodation in order to participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact the Eleventh Judicial Circuit Court’s ADA Coordinator, Lawson E. Thomas Courthouse Center, 175 NW 1st Ave., Suite 2702, Miami, FL 33128, Telephone (305) 349-7175; TDD (305) 349-7174, Fax (305) 349-7355 at least 7 days before your scheduled court appearance, or immediately upon receiving this notification if the time before the scheduled appearance is less than 7 days; if you are hearing or voice impaired, call 711.” CLK/CT. 150 Rev. 05/11 Clerk’s web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com