COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: ______________________________Reference No.: ______________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Plaintiff(s)/Counter Defendant(s) Address: vs. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Address: Defendant(s)/Counter Plaintiff STATEMENT OF COUNTER CLAIM Defendant(s)/Counter Plaintiff(s) sues(s) the Plaintiff(s)/Counter Defendant(s) for damages which do not exceed $5,000.00, exclusive of costs, interest, and attorneys fee for (as checked (X) below): ( ) Goods, wares and merchandise sold by Plaintiff(s) to Defendant(s): ( ) Work done and materials furnished by Plaintiff(s) to Defendant(s): ( ) Money loaned by Plaintiff(s) to Defendant(s): ( ) On a written instrument, copy of which is attached hereto: ( ) (Rent) (Security Deposit) for certain premises in Pinellas County, Florida, located at: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( ) Other (explain) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( ) Any additional facts in connection with any of the above: (Use additional sheets if necessary) WHEREFORE, Defendant/Counter Plaintiff(s) demands judgment in the principal amount of $ __________________ plus costs, interest, and attorneys fee. STATE OF FLORIDA : COUNTYOF PINELLAS : ss. Defendant(s)/Counter Plaintiff(s) _________________________________________________________________ ____ (Please print Plaintiffs name exactly as it appears at top of form.) states that the foregoing is a just and true statement of the amount owing 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. I certify that I have mailed/hand-delivered to Plaintiff/Counter Defendant a copy of this counter claim this date. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signature of Attorney for Plaintiff(s) or Agent Signature of Defendant(s) or Agent/Counter Plaintiff(s)Address: __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Title _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Telephone No. ____________________________________Telephone No.: Sworn to and subscribed before me this _______ day of _______________________ , 20 _______ . ________________________________________________ SPN No. Deputy Clerk or Notary Public State of Florida My Commission expires: SC 076 (Rev. 1/1/03) SC076 12/02 American LegalNet, Inc. www.USCourtForms.com