COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: ______________________________ Reference No.: ______________________________ __________________________________________________________________________ __________________________________________________________________________ Plaintiff(s), vs. __________________________________________________________________________ FACT INFORMATION SHEET __________________________________________________________________________ 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 the 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: $ ________________ 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 are 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: $ ________________________________ 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.) SC 104 (Rev. 1/1/03) SC104 12/02 American LegalNet, Inc. www.USCourtForms.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 sale 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: a. Your last pay stub. b. Your last 3 statements for each bank, savings, credit union, or other financial account. c. Your motor vehicle registrations and titles. d. 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 PINELLAS : ss. The foregoing instrument was acknowledged before me this _________________ day of _______________________ . 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, this ___________ day of ___________________________ A.D., 20 ______ . My Commission expires: _____________________________ _______________________________________________ Notary Public State of Florida MAIL OR DELIVER THIS FORM TO THE CLERK OF THE COURT, AND MAIL OR DELIVER A COPY OF THE COMPLETED FORM TO THE JUDGMENT CREDITOR OR THE CREDITOR'S ATTORNEY. SC 104 (Rev. 1/1/03) SC104 12/02 American LegalNet, Inc. www.USCourtForms.com