IN THE COUNTY COURT OF POLK COUNTY, FLORIDA CIVIL DIVISION CASE NO. _________________ Plaintiff, vs. Defendant. __________________________________/ DEFICIENCY STATEMENT OF CLAIM The above named Plaintiff sues the above named defendant and alleges: 1. This is an action for damages which do not exceed $5000.00, exclusive of costs, interest and attorney's fees. 2. On _________________________, plaintiff and defendant entered into a written contract, a copy of which is attached, marked Exhibit A. 3. Defendant failed to make the payment due on said contract on _______________________ at which time there was still a balance of $_______________ due to plaintiff. 4. Plaintiff subsequently took possession of the following described property pursuant to the security interest retained by the terms of the said contract: 5. On _________________________, the above described property was sold at public/private sale after written notice was duly made upon defendant. A copy of said notice is attached, marked Exhibit B. 6. The proceeds of said sale in the amount of $_______________ were applied to the balance owed to plaintiff by defendant, and after appropriate adjustment for prepaid interest and/or insurance and costs of repossession and sale of the property which are itemized and attached as Exhibit C, defendant owed a remaining balance of $_______________ to plaintiff. 7. Plaintiff notified defendant of the remaining balance on _________________________. 8. Plaintiff says that the foregoing is a just and true statement of the amount owing by the above named defendant, and that the action has been brought in the County in which venue is proper, pursuant to Chapter 47, Florida Statutes. ________________________________________ Plaintiff ____________________ Phone 2000 © American LegalNet, Inc. Subscribed and sworn to before me this _____ day of Personally Known __________________, 20____ RICHARD M. WEISS, Clerk BY___________________________D.C. ________________________ ____ Produced Identification ____ Type of identification presented: OR BY___________________________ Notary Public/My Commission Expires: 21.doc (08/97) 2000 © American LegalNet, Inc.