IN THE COUNTY COURT IN AND FOR SANTA ROSA COUNTY, FLORIDA SMALL CLAIMS DIVISION Case # ________________________ Plaintiff(s) Address: _______________________________________________ _______________________________________________ Telephone # _______________________________________________ VS Defendant(s) _______________________________________________ Address: Telephone # _______________________________________________ _______________________________________________ STATEMENT OF CLAIM Plaintiff(s) claims the amount of $__________________ as being due from the defendant(s) together with $_______________ for interest plus court cost of $_____________________ which all totals $________________________, and alleges that the basis of this suit is: _____ Money due plaintiff upon accounts stated and agreed to between them _____ Money loaned by plaintiff to defendant. _____ Goods, wares, and merchandise sold by plaintiff to defendant. _____ Rent due plaintiff for certain premises in Santa Rosa County, Florida. _____ Plaintiff further states the suit is bases on a written instrument. _____ Money due plaintiff for worthless check given by defendant. _____ Money due plaintiff for labor and materials furnished to defendant. ._____ Defective goods, workmanship, or services furnished by plaintiff to defendant. Describe defects, list of goods: ______________________________________________________________________________ _____ Damages due to auto collision. Describe defendants negligent act which caused collision: ______________________________________________________________________________ _____ Other STATE OF FLORIDA COUNTY OF SANTA ROSA The undersigned, being duly sworn, says that the foregoing is a just and true statement of the amount owing by the defendant(s) to said plaintiff(s) exclusive of all set-offs and just grounds of defense: Sworn and subscribed before me this ______________ day of _______________, 20_________. __________________________________ __________________________________________ Plaintiff(s) Deputy Clerk or Notary NOTICE: THIS DOCUMENT REQUIRES AN OFFICIAL COURT SUMMONS WITH SIGNATURE AND THE OFFICIAL COURT SEAL AFFIXED THERETO. 5 American LegalNet, Inc. www.FormsWorkFlow.com