COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: ______________________________ Reference No.: ______________________________ _________________________________________________________________ _________________________________________________________________ Address: Plaintiff(s) vs. _________________________________________________________________ _________________________________________________________________ Address: Defendant(s) STATEMENT OF CLAIM - AUTO ACCIDENT Plaintiff(s) sue(s) the Defendant(s) for damages which do not exceed $5,000.00, exclusive of costs, interest and attorney’s fee (if appropriate) and allege(s): 1. On _________________________ , 20 ___ , Defendant(s) owned and/or operated a motor vehicle at ____________________________________________________________ , Pinellas County, Florida. (place) 2. At the time, the Defendant(s) negligently operated or maintained the motor vehicle so that a collision occurred between Plaintiff(s) _________________________________________________________ and Defendant(s) motor vehicle. (motor vehicle or property) 3. As a result, Plaintiff(s), was/were injured and/or sustained damages to his/their motor vehicle/property. 4. Plaintiff(s) automobile is a ____________________________________________________________ (year, make, model of automobile) WHEREFORE, Plaintiff(s) demand judgment in the principal amount of $ _____________________ determined as follows: _________________________________________________________________________________________________________________________ together with costs, interest and attorney’s fee. STATE OF FLORIDA : COUNTY OF PINELLAS: ss. Plaintiff ____________________________________________________________________________ (Please print Plaintiff’s/Plaintiffs’ name exactly as it appears at top of form.) states/state that the foregoing is a just and true statement of the amount owed by Defendant(s) to Plaintiff(s) exclusive of all set-offs and just grounds of defense. Affiant states that Defendant(s) is/are not in the military service of the United States. _________________________________________________________ Signature of Attorney for Plaintiff(s) __________________________________________________________ Signature of Plaintiff(s) or Agent Address: ______________________________ ______________________________ __________________________________________________________ Title Telephone No. _____________________________ _______________________________________________________ Telephone No. _____________________________________ Sworn to and subscribed before me this SPN No. __________________________________ __________ day of _______________________ , ______ . ___________________________________________________ Auto Accident SC 056 (Rev. 1/1/03) Deputy Clerk or Notary Public State of Florida My Commission expires: SC 056 12/02 American LegalNet, Inc. www.USCourtForms.com