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. 2. On or about ____________________ , ________ , Plaintiff(s), Landlord(s), leased to Defendant(s), Tenant(s), premises located at __________________________________________________________________ , Pinellas County , Florida. 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. 4. Defendant(s) vacated the premises on or about _______________________________________________ , _______ . 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. 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 - Unpaid Rent SC 044 (Rev. 9/24/08) SC 044 9/24/08 American LegalNet, Inc. www.FormsWorkFlow.com