IN THE COUNTY COURT OF THE NINTH JUDICIAL CIRCUIT OF FLORIDA ORANGE COUNTY, FLORIDA Case Number_______________ Plaintiff(s) VS Defendant(s) STATEMENT OF CLAIM CHECK-PAYEE VS. DRAWER The above named Plaintiff(s) sue(s) the above named Defendant(s) for: On or about____________________,____________________________ issued_______ check payable to__________________________, for the sum of $______________drawn on________________________, a copy of which is annexed hereto as Exhibit "A". Plaintiff(s) presented said check to said bank for payment and payment was refused with the words "_________________________" stamped on the front/back thereof, of which defendant had due notice. And Plaintiff(s) claim(s) $_________ damages, such interest and attorney’s fees and court costs as are lawful. ________________________________ Plaintiff(s) 2000 © American LegalNet, Inc.