COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: ______________________________ Reference No.: ______________________________ ________________________________________________________ Address: Plaintiff(s) vs. ________________________________________________________ Address: Defendant(s) STATEMENT OF CLAIM - LANDLORD/TENANT - 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 alleges(s): 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: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ (length of lease in months or years; amount of rent payment; notice requirement for vacating the premises; amount of security deposit; and 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) failed to pay rent for the periods of _______________________________________________________ , leaving rent due and owing of $ ______________________ WHEREFORE, Plaintiff(s) demand judgment in the principal sum of $ __________ plus 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. _______________________________ Sworn to and subscribed before me this _______________________________________________________________ Telephone No. ______________________________________________ SPN No. ________________________________________ ________ day of ________________________ , __________ . _____________________________________________________ Landlord/Tenant - Unpaid Rent SC 044 (Rev. 1/1/03) Deputy Clerk or Notary Public State of Florida My Commission expires: SC 044 12/02 American LegalNet, Inc. www.USCourtForms.com