IN THE COUNTY COURT IN AND FOR OKALOOSA COUNTY, FLORIDA SMALL CLAIMS DIVISION _________________________________________ Plaintiff(s) vs. _________________________________________ Defendant(s) Case No. _______________________ FACT INFORMATION SHEET --- INDIVIDUAL Full Legal Name:______________________________________________________________ Nicknames or Aliases:__________________________________________________________ Residence Address:____________________________________________________________ Mailing Address (if different):_____________________________________________________ Telephone Numbers: (Home)___________________(Business)_________________________ Name of Employer:_____________________________________________________________ Position or Job Description:______________________________________________________ Rate of Pay: $_________ per _________. Average Paycheck: $__________ per ___________ Average Commissions or Bonuses: $___________ per _____________. Commissions or bonuses are based on:_________________________________________________________ Other Personal Income: $_________________ from __________________________________ (Explain details on the back of this sheet or an additional sheet if necessary.) Social Security Number: ___________________________ Birthdate:_____________________ Driver's License Number:________________________________________________________ Marital Status:___________ Spouse's Name:________________________________________ Spouse's Address (if different):___________________________________________________ Spouse's Social Security Number:______________________ Birthdate:__________________ Spouse's Employer:____________________________________________________________ Spouse's Average Paycheck or Income: $________________ per _______________________ Other Family Income: $___________________ per __________________ (Explain details on back of this sheet or an additional sheet if necessary.) 1 Form 7.343 Individual 2011 American LegalNet, Inc. www.FormsWorkFlow.com Names and ages of All Your Children (and addresses if not living with you): ____________________________________________________________________________ ________________________________________________________________ Child Support or Alimony Paid: $____________________ per ____________________ Names of Others You Live With:____________________________________________ Who is Head of Your Household? ____ You ____ Spouse ____________Other Person Checking Account at: _____________________ Account # ______________________ Savings Account at: ______________________ Account # ______________________ (Describe all other accounts or investments you may have, including stocks, mutual funds, savings bonds, or annuities, on the back of this sheet or an additional sheet, if necessary.) For Real Estate (Land) You Own or Are Buying: Address:_______________________________________________________________ All Names on Title:_______________________________________________________ Mortgage Owed to:_____________________________________________________________ Balance Owed: _______________________________________________________________ Monthly Payment: $ ____________________________________________________________ (Attach a copy of the deed or mortgage, or list the legal description of the property on the back of this sheet or an additional sheet if necessary. Also provide the same information on any other property you own or any buying.) For All Motor Vehicles You Own or Are Buying: Year/Make/Model: ________________________ Color: _______________________________ Vehicle ID #: ______________________ Tag No: _____________ Mileage: _______________ Names on Title: ______________________________ Present Value $ ___________________ Loan Owed to: ________________________________________________________________ Balance on Loan: $ _________________________________ (List all other automobiles, as well as other vehicles, such as boats, motorcycles, bicycles, or aircraft, on the back of this sheet or an additional sheet if necessary.) ____________________________________________________________________________ ____________________________________________________________________________ 2 Form 7.343 Individual 2011 American LegalNet, Inc. www.FormsWorkFlow.com Have you given, sold, loaned, or transferred any real or personal property worth more than $100 to any person in the last year? If your answer is "Yes," describe the property and sales price, and give the name and address of the person who received the property._____________________________________________________________________ ________________________________________________________________ Does anyone owe you money? Amount Owed? ________________________________ Name and Address of Person Owing Money:__________________________________ Reason money is owed: __________________________________________________ Please attach copies of the following: 1. Your last pay stub. 2. Your last 3 statements for each bank, savings, credit union or other financial account. 3. Your motor vehicle registrations and titles. 4. Any deeds or titles to any real or personal property you own or are buying, or leases to property you are renting. UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE TRUE AND COMPLETE. ______________________________ Judgment Debtor STATE OF FLORIDA COUNTY OF ______________________________ The foregoing instrument was acknowledged before me on ________, 20___, by _______________________________________, who is personally known to me or has produced ____________________________ as identification and who ____ did/did not ______ take an oath. WITNESS my hand and official seal, on ______________________, 20______. _______________________________ My commission expires: Notary Public State of Florida MAIL OR DELIVER THE COMPLETED FORM TO THE JUDGMENT CREDITOR OR THE JUDGMENT CREDITOR'S ATTORNEY. 3 Form 7.343 Individual 2011 American LegalNet, Inc. www.FormsWorkFlow.com