IN THE COUNTY COURT OF THE NINTH JUDICIAL CIRCUIT OF FLORIDA ORANGE COUNTY, FLORIDA Case Number____________________ ______________________________ (Name) ______________________________ (Street Address) ______________________________ (City, State, and Zip) ______________________________ (Phone Number) Plaintiff(s) VS ______________________________ (Name) ______________________________ (Street Address) ______________________________ (City, State, and Zip) ______________________________ (Phone Number) Defendant(s) STATEMENT OF CLAIM The above named Plaintiff(s) sue(s) the above named Defendant(s) for: (Explain your claim here) And Plaintiff(s) claim(s) $___________damages not to exceed $5,000.00 exclusive of interest, court costs and attorney fees. (Dollar amount is without court costs) ___________________________________ Plaintiff(s) (Sign here) American LegalNet, Inc. www.FormsWorkflow.com