COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: ______________________________ Reference No.: ______________________________ ______________________________________________________________ ______________________________________________________________ Address: Plaintiff(s) vs. ______________________________________________________________ ______________________________________________________________ Address: Defendant(s) STATEMENT OF CLAIM LANDLORD/TENANT - DAMAGES TO PREMISES AND UNPAID RENT 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): COUNT I 1. On or about , ___________________________ , ___________ , Plaintiff(s), Landlord(s), leased to Defendant(s), Tenant(s), premises located at _______________________________________________________________________________________ , Pinellas County, Florida. 2. The lease was an oral lease containing the following provisions: ________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________ (Set out length of lease in months or years; amount of rent payment; the notice requirement for vacating the premises; amount of security deposit; and, the amount of prepaid last month's rent, if any.) — OR — ________________________________________________________________________________________________________________________________________________________ (A copy of the written lease is attached.) 3. Defendant(s) vacated the premises on or about __________________________________________________________ , ________ . 4. Defendant(s) left damages in the amount of $ ____________________________ , as follows: ___________________ ___________________ item ___________________ ___________________ item $ __________________ _________________ amount ___________________ ___________________ Item $ __________________ _________________ amount ___________________ ___________________ Item $ __________________ _________________ amount $ __________________ _________________ amount WHEREFORE, Plaintiff(s) demand judgment in the sum of $ ______________________ , together with costs, interest, and attorney’s fee. COUNT II 1. On or about _______________________________ , Plaintiff(s), Landlord(s), leased to the Defendant(s), Tenant(s), premises located at _____________________________________________________________________________________ Pinellas County, Florida. 2. The lease was an oral lease containing the provisions as set out in paragraph 2 of Count I of this Statement of Claim. — OR — ________________________________________________________________________________________________________________________________________________________ (A copy of the written lease is attached.) 3. Defendant(s) failed to pay rent for the period of ____________________________________________ , leaving rent due and owing of $ ________________________________ . 4. Defendant(s) vacated the premises on or about ____________________________________________________________ . WHEREFORE, Plaintiff(s) demand judgment in the principal sum of $ ________________________ plus costs, interest and attorney's fee. STATE OF FLORIDA : ss. COUNTY OF PINELLAS: 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. ___________________________________ Sworn to and subscribed before me this _______________________________________________________________________ Telephone No. _____________________________________________________ SPN No. ______________________________________________ Landlord/Tenant - Damages to Premises and Unpaid Rent SC 057 (Rev. 1/1/03) ________ day of _____________________________ , __________ . __________________________________________________________ Deputy Clerk or Notary Public State of Florida My Commission expires: American LegalNet, Inc. www.USCourtForms.com SC 057 12/02