IN THE COUNTY COURT IN AND FOR MIAMI-DADE COUNTY, FLORIDA. DIVISION CIVIL DISTRICTS OTHER PLAINTIFF (BACK RENT) (File in Duplicate Plus One For Each Defendant) VS. DEFENDANT(S) CASE NUMBER STATEMENT OF CLAIM SECTION NO. CLOCK IN The Plaintiff sues the Defendant for money owed Plaintiff by Defendant; and which is past due and unpaid; for (As marked (x) below): Address: Phone Number: Rent for certain premises in Miami-Dade County, Florida, Viz; Plaintiff (Landlord) sues defendant for payment of back rent for the premises known as ___________________________________ rent has been owning since ___________________________, 20 _______, at $ _______________ per _____________ making a total of $ _______________ due as of this date. 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 Attorney's 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_____. HARVEY RUVIN CLERK OF COURTS NOTARY PUBLIC, State of Florida _____________________ My Commission Expires: Clerk's web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com _________________________________ Deputy Clerk IMPORTANT: SEE REVERSE CLK/CT. 791 Rev. 06/11 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 defendant's 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 plaintiff's 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 "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. 791 Rev. 06/11 Clerk's web address: www.miami-dadeclerk.com American LegalNet, Inc. www.FormsWorkFlow.com