IN THE COUNTY COURT, IN AND FOR SEMINOLE COUNTY, FLORIDA PLAINTIFF(S) NAME (PRINT OR TYPE) CASE NO. STREET ADDRESS CITY, STATE, ZIP CODE PLAINTIFF(S) TELEPHONE: SUES STATEMENT OF CLAIM DEFENDANT(S) NAME (PRINT OR TYPE) STREET ADDRESS CITY, STATE, ZIP CODE DEFENDANT(S) TELEPHONE: And claims the amount of $ together with $ interest, plus court costs of $ , which total $ , as being due from the Defendant(s) and alleges as the basis of such suit the following matters: Plaintiff further states that the Defendant is/ is not in the Military Service of the United States. Plaintiff further states that a copy of the written instrument or invoice on which this suit is based is attached hereto. The undersigned, being duly sworn, says that the foregoing is a just and true statement of the amount owing the Plaintiff by said Defendant, exclusive of all setoffs and just grounds of defense, and that this suit is brought in good faith. State of Florida County of Signature of Plaintiff/Attorney for Plaintiff/Corporate Agent The foregoing instrument was acknowledged before me on , Address by , who is City State Zip Code personally known to me or has produced as identification and (Area Code) Telephone Number who did / did not take an oath Email Address WITNESS my hand and official seal, on Deputy Clerk/Notary Public, State of Florida Distribution: White-Original Yellow/Pink-Defendants Goldenrod-Plaintiffs SCa.001 American LegalNet, Inc. www.FormsWorkFlow.com GRANT MALOY CLERK OF THE CIRCUIT AND COUNTY COURTS AND COMPTROLLER P.O. BOX 8099 SANFORD, FLORIDA 32772 NOTICE TO PLAINTIFF(S): 1. ; (2) What was done that gives rise to the claim; (3) When it occurred(date, month and year); (4) Where it occurred (city , county and state); (5) How much money is due you; (6) If you are entitled to interest on the money due you, you must state it separately, showing the amount of interest due you to date you file the claim. Also, give a per diem interest rate so that the Court may easily compute the amount of interest due from the date the claim is filed to the date the judgment is entered. The jurisdictio n of this Court is $ 5 , 000 . 00 exclusive of interest , costs and attorney' sfees, if applicable . If your claim is for more than this amount, you may wish to filesuit in the County Civil Court. WHEN 4. WHEN 5. If 6.The filing fees for Small Claims suits in Seminole County are as follows : Fo r c l a im s : Filing Fee Less than $ 100 . 00 $ 55 . 00 $ 100 . 00 to $ 500 . 00 $ 80 . 00 $500 . 01 to $ 2 , 500 . 0 0 $ 175 . 00 $ 2 , 500 . 01 to $ 5 , 000 . 00 $ 300 . 00 There is an additional fee of $ 10 . 00 for each summons issued. 7.Where appropriate , at the discretion of the Court, the above costs are added by the Court to the amount of your claim at the time judgment is entered . DO NOT ADD SUCH COSTS INTO THE AMOUNT STATED BY YOU AS THE AMOUN T CLAIMED IN THE STATEMEN T OF CLAIM. 8.The address of each defendant must be given in detail for deliver y of NOTICE TO APPEARby mail; or, for the sheriff or certified process server to find the defendant , if thedefendant is to be personally served.9.YOU ARE REQUIRE D TO BE PRESENT AT THE PRE - TRIAL HEARING . IF YOU FAIL TO APPEAR AND THEDEFENDAN T APPEARS , YOUR CLAIM MAY BE DISMISSE D FOR LACK OF PROSECUTION , DEFENDAN T MAYPROCEED TO TRIAL ON THE MERITS, OR THE CASE MAY BE CONTINUE D AS THE JUDGE MAY DIRECT.NOTICE TO BOTH PLAINTIFF(S) AND DEFENDANT(S); 1.Witnesses are not needed at Pre - Trial Conference . If your case cannot be settled at Pre - Trial, the Judge will set case for Trial . Your witnesses should be subpoenaed to appear at Trial. 2.You may come with or without an attorney .3.YOU ARE ENCOURAGE D TO CONTACT THE OPPOSIN G PARTY TO DETERMINE IF AN OUT - OF - COURTSETTLEMEN T CAN BE REACHED . IF SETTLEMEN T IS REACHED , PLAINTIF F SHOUL D ADVISE THE CLERKIN WRITING SO THAT THE CASE CAN BE REMOVED FROM THE COURT' S DOCKET. SCb.001 American LegalNet, Inc. www.FormsWorkFlow.com