COUNTY COURT, OKALOOSA COUNTY, FLORIDA SMALL CLAIMS DIVISION PLAINTIFF(S): ___________________________________________ ___________________________________________ ___________________________________________ -vsDEFENDANT(S): ___________________________________________ ___________________________________________ ___________________________________________ STATEMENT OF CLAIM Plaintiff claims the amount of $______________as being due from the Defendant(s) together with $_____________for Interest and $______________ for Attorney's Fees, plus court costs of $_________________ which all totals $_________________ and alleges that the basis of this suit is: [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] Money due plaintiff on account. (See attached copy of the accounts.) Goods, wares and merchandise sold by plaintiff to defendant. (List of goods and prices below). Money loaned by plaintiff to defendant. (Copy of any promissory note attached). Rent due plaintiff for certain premises. (List below: (1) address of premises and (2) amount and date of rent past due And attach copy of any written lease). Defective goods/workmanship/services furnished by defendant. (List time, materials and charges below). Money due plaintiff for labor and materials furnished to defendant. (List time, materials and charges below). Money due plaintiff for worthless check given by defendant. (List time, materials and charges below). Money due plaintiff for worthless check given by defendant. (See attached copy of check). Damages due to auto collison. (Describe below: (1) defendant's negligent act which caused collision and (2) nature and amount of damages). Damages due to breach of contract or an implied/express warranty defendant. (Describe below: The nature of the contact and the breach). OTHER: CASE NO.____________________ [] [] ADDITIONAL INFORMATION: STATE OF FLORIDA ­ COUNTY OF OKALOOSA THE PLAINTIFF(S) IN THE ABOVE STYLED CAUSE, UPON OATH DEPOSES THAT THE FOREGOING IS A JUST AND TRUE STATEMENT OF THE AMOUNT OWING BY THE DEFENDANT(S) TO SAID PLAINTIFF(S) EXCLUSIVE OF ALL SET-OFFS AND JUST GROUNDS OF DEFENSE. Plaintiff(s) further states that the Defendant(s) (check one) [ ] is [ ]is not in the military service of the United States. Sworn to and subscribed before me this ________ day of _________________________, 20_______. Plaintiff 1._____________________________________ Plaintiff 2. ______________________________________ JD PEACOCK II, CLERK OF COURT By:______________________________________ Deputy Clerk or Notary Public Complete in Triplicate 11/03/2014 American LegalNet, Inc. www.FormsWorkFlow.com