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. 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. _____________________________________________________ _______ day of _______________________ , __________ . SPN No. ______________________________________________ ________________________________________________ Landlord/Tenant - Security Deposit Refund SC 046 (Rev. 1/1/03) American LegalNet, Inc. www.USCourtForms.com Deputy Clerk or Notary Public State of Florida My Commission expires: SC 046 12/02 American LegalNet, Inc. www.USCourtForms.com