COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: Reference No.: vs. Defendant 1 Plaintiff(s) Defendant 2 Defendant(s) Address: Address: STATEMENT OF CLAIM Plaintiff(s) sue(s) the Defendant(s) for damages which do not exceed $5,000.00 exclusive of costs, interest and attorney's fee for (check one category below): ( ( ( ) Auto Accident ) Bad Check - Select one: ( ) insufficient funds ( ) stop payment ( ) other ) Breach of Agreement - Select one: ( ) oral agreement ( ) written agreement Select one: ( ) Goods or merchandise ­ Select one: ( ) sold by Plaintiff ( ) received by Plaintiff ( ) Money paid for either goods or services not provided ( ) Services including materials ­ Select one: ( ) rendered by Plaintiff ( ) received by Plaintiff ( ) Wages including salary, commission or fees ) Money loaned - Select one ( ) oral loan ( ) written loan ) Rent/Property Damage - Select one ( ) oral lease ( ) written lease Amount claimed for Rent: ___________ Amount claimed for Property Damage: ) Security Deposit claim ) Other claim ­ Please specify: ________________________________________________________ ( ( ( ( Explain below the details (what happened, dates, times, place, etc) of your claim. This section must be completed. ( ) Attached is a copy of any written document(s) that is the basis of this claim. WHEREFORE, the Plaintiff(s) demand judgment in the principal sum of $ plus costs in the amount of $ plus interest in the amount of $ plus attorney's fee in the amount of $ Under penalties of perjury, I / We declare that I / We have read the foregoing statement of claim, that the facts stated in it are true, and that Defendant(s) is/are not in the military service of the United States. Signature of Attorney for Plaintiff(s) Plaintiff or Attorney Address: Signature of all Plaintiff(s) or Company Representative Print name of all Plaintiff(s) or Company Representative Title (if applicable) Atty Telephone No. Atty SPN No. SC 002 (Revised 6/05) ­SelfHelp Revision ­ 9/2007 American LegalNet, Inc. www.FormsWorkFlow.com Telephone No.