IN THE COUNTY COURT IN AND FOR SANTA ROSA COUNTY, FLORIDA Case # ________________________ _______________________________________________ Plaintiff(s) Vs _______________________________________________ Defendant(s) STATEMENT OF CLAIM AUTO NEGLIGENCE The plaintiff(s) sues the defendant(s) and says: on or about _______________________, in the vicinity of _______________________________________________________________, on a public highway in Santa Rosa County, Florida, plaintiff's motor vehicle, being operated by ____________________________, collided with defendant's motor vehicle being operated by ____________________________, and the collision with the plaintiff's vehicle was caused by the negligent and careless operation of defendant's vehicle whereby plaintiff's vehicle was damaged and depreciated in value. WHEREFORE, Plaintiff(s) demands judgment in the sum of $_________________ and Court Costs in the amount of $________________________. 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. American LegalNet, Inc. www.FormsWorkFlow.com