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. DIVISION CIVIL DISTRICTS OTHER PLAINTIFF STATEMENT CASE NUMBER PLAINTIFF(S) (Person(s) filing the lawsuit) VS. DEFENDANT(S) (Person(s) the lawsuit is filed against) CLOCK IN ADDRESS and PHONE NO.(s) 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 BY: DEPUTY CLERK DATE CLK/CT. 150 Rev. 10/18 Clerk222s 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)003 An individual, give his/her full name address in the space provided above. (C)003 A Business Firm, give the Firm Name and the Name of the Owner and Addresses of each in the spaces provided. (D)003 A Partnership, you must name all of the Partners and their addresses in the spaces provided. (E)003 A Corporation, give it222s Full Name, state where incorporated, and the names and addresses of its Officers in the spaces provided. (F)003 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)003 If you are unable to determine which of the above applies to your case, please see the clerk. AMERICANS WITH DISABILITIES ACT OF 1990002 ADA NOTICE002 223If 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 Court222s ADA Coordinator, Lawson E. Thomas Courthouse Center, 175 NW 1 st Avenue, Suite 2400, Miami, FL 33128; Telephone (305) 349-7175; TDD (305) 349-7174, Email ADA@jud11.flcourts.org ; or via Fax at (305) 349- 7355, at least seven (7) days before your scheduled court appearance, or immediately upon receiving this notification if the time before the scheduled appearance is less than seven (7) days; if you are hearing or voice impaired, call 711.224 CLK/CT. 150 Rev. 10/18003 Clerk222s web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com