IN THE COUNTY COURT IN AND FOR MIAMI-DADE COUNTY, FLORIDA. CASE NUMBER STATEMENT OF CLAIM DIVISION CIVIL (AUTO NEGLIGENCE) DISTRICTS (File in Duplicate Plus One For Each Defendant) SECTION NO. PLAINTIFF OTHER VS. DEFENDANT(S) CLOCK IN The Plaintiff sues the Defendant for money Address: Phone Number: owed Plaintiff by Defendant; and which is past due and unpaid; for (As marked (x) below): AUTO NEGLIGENCE Any additional facts in connection with the above: (Use additional sheet if necessary) The plaintiff sues the defendant and says: On or about , in the vicinity of , on a public highway in County, Florida, plaintiff222s motor vehicle, being operated by , collided with defendant222s motor vehicle, being operated by , and the collision with plaintiff222s vehicle was caused by the negligent and careless operation of defendant222s vehicle, whereby plaintiff222s vehicle was damaged and depreciated in value. (See Attached) Where Plaintiff demands judgment in the sum of $ together with court costs and any further costs which the Court may assess. The Plaintiff, says the foregoing is a just and true statement of the amount owed by defendant to plaintiff, exclusive of all lawful setoffs, and that defendant has no lawful defenses which would preclude the collection of said amount. Affiant states that the defendant(s) is/are not in the military service of the United States. Attorney/Plaintiff Signature Attorney222s Bar No. Address of Attorney/Plaintiff Telephone No. The foregoing instrument was acknowledged before me this day of , 20 by who is personally known to me or who has produced as identification and did / did not take an oath. SWORN TO AND SUBSCRIBED BEFORE ME this day of 20. NOTARY PUBLIC, HARVEY RUVIN CLERK OF COURTS State of Florida Deputy Clerk My Commission Expires: IMPORTANT: SEE REVERSE CLK/CT. 790 Rev. 03/19 Clerk222s web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com SERVICE OF PROCESS PROCESS SERVER SHERIFF MAIL FILING FEE AMOUNT RECEIPT NUMBER NOTE: If the claim is based upon a written document, a copy, or the material part thereof, shall be attached to the statement of claim. INSTRUCTION SHEET IMPORTANT YOU MUST advise the Clerk, in writing, of any change in your mailing address. If you are a DEFENDANT and fail to appear on the designated date, in person or by an attorney, a judgment may be entered against you. Plaintiff(s) will not be entitled to a default or judgment in the absence of an affidavit regarding the defendant222s military status in compliance with applicable law. This form, if sworn to, will meet the above requirements. If you are a PLAINTIFF and fail to appear on the designated date, in person or by an attorney, this case may be dismissed for Want of Prosecution. Any claim of the Defendant against the Plaintiff, arising out of the same transaction or occurrence which is the subject matter of plaintiff222s claim, shall be filed not less than 5 days prior to the appearance date, or within such times as the Court designates. When a counterclaim or set-off exceeds the jurisdiction of the Court, it shall be filed in writing before or at the pretrial hearing, and the action shall then be transferred to the Court having jurisdiction thereof. As evidence of good faith, the counter-claimant shall deposit a sum sufficient to pay the filing fee in the Court to which the case is to be transferred with his counterclaim. FAILURE TO MAKE THE DEPOSIT WAIVES THE RIGHT TO TRANSFER. TRIAL BY JURY may be had upon written demand by Plaintiff made at the commencement of the action or by any defendant within 5 days after service of the notice to appear or at the Pretrial Conference. If the demand is not made, the right to trial by jury is waived. If at any time in the proceedings a settlement is reached between the parties, this office should be notified in writing by the Plaintiff. If you have any questions regarding procedures, this office will assist you. This office cannot furnish legal advice to you. Please consult your attorney for legal advice. CAUTION A copy of any paper that you file at any time with the Clerk or Judge MUST be sent by you to each attorney appearing in the case, if any, or to all parties not represented by an attorney. You must set forth the date and to whom you sent the copy (or copies) of the paper filed, which would be followed by your signature. AMERICANS WITH DISABILITIES ACT OF 1990 ADA NOTICE 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 Aliean Simpkins, the Eleventh Judicial Circuit Court222s ADA Coordinator, Lawson E. Thomas Courthouse Center, 175 NW 1st 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. 790 Rev. 03/19 Clerk222s web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com