COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: Reference No.: Plaintiff(s), vs FACT INFORMATION SHEET — INDIVIDUAL Defendant(s), Full Legal Name: Nicknames or Aliases: Residence Address: Mailing Address (if different): Telephone Numbers: (Home) (Business) Name of Employer: Address 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.) Names and Ages of All Your Children (and addresses if not living with you): Child Support or Alimony Paid: $ Names of Others You Live With: Who is Head of Your Household? Checking Account at: Savings Account at: per You Account # Account # Spouse Other Person (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 are buying.) SC 104 (Rev. 6/2011 per update to Small Claims Rules) SC104 12/02 American LegalNet, Inc. www.FormsWorkFlow.com 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: $ Monthly Payment: $ (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.) Have you given, sold, loaned, or transferred any real or personal property worth more than $100 to any If your answer is “yes,” describe the property and sale price, and person in the last year? 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 .(date), 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 (date). ___________________________ Notary Public State of Florida My Commission expires: MAIL OR DELIVER THE COMPLETED FORM TO THE JUDGMENT CREDITOR OR THE JUDGMENT CREDITOR’S ATTORNEY. DO NOT FILE THIS FORM WITH THE COURT. SC 104 (Rev. 6/2011 per update to Small Claims Rules) SC104 12/02 American LegalNet, Inc. www.FormsWorkFlow.com