COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: ______________________________ Reference No.: ______________________________ ________________________________________________________ ________________________________________________________ Address: Plaintiff(s) vs. ________________________________________________________ ________________________________________________________ Address: Defendant(s) STATEMENT OF CLAIM - LANDLORD/TENANT - SECURITY DEPOSIT REFUND Plaintiff(s) sue(s) the Defendant(s) for damages which do not exceed $5,000.00, exclusive of costs, interest and attorney's fees (if appropriate) and allege(s): 1. On or about _________________________ , ________ , Plaintiff(s) lease _______________________________________located at (an apartment/residence) _______________________________________________________________________, Pinellas County, Florida, from Defendant(s). ______________________________________________________________________ 2. The lease was an oral lease containing the following provisions: _______________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ (length of lease in months or years; amount of rent payment; amount of security deposit; amount of prepaid last month's rent, if any; and any other provisions relevant to these proceedings.) -OR___________________________________________________________________________________________________________ (a copy of the written lease is attached) 3. Plaintiff(s) vacated the premises on or about _______________________ , _______ . 4. Plaintiff(s) demanded return of (security deposit or last month's rent) by ___________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ (in person request to - name and title of person - on whatever date; or by certified letter mailed to - name and title of person on whatever date; or by regular mail to - name and title of person on whatever date; or set out by whatever other method used). 5. Defendant(s) has/have refused to return the security deposit or last month's rent requested. WHEREFORE, Plaintiff(s) demand judgment in the principal sum of $ ____________________ plus costs, interest and attorney's fee. 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) Address: _________________________________________ _________________________________________ _______________________________________________________________________ Telephone No. _____________________________________________________ SPN No. ______________________________________________ ____________________________________________________________________ Signature of Plaintiff(s) or Company Representative ____________________________________________________________________ Print name of all Plaintiff(s) or Company Representative Telephone No. ____________________________________ ________________________________________________ Title (if applicable) Landlord/Tenant - Security Deposit Refund SC 046 (Rev. 9/24/08) SC 046 9/24/08 American LegalNet, Inc. www.FormsWorkFlow.com