Joseph E. Smith Clerk of the Circuit Court St. Lucie County, Florida County Civil division 250 N.W. Country Club Drive Port Saint Lucie, Florida 34986 (772) 785-5880 In the County Court, Nineteenth Judicial Circuit, in and for County of St. Lucie, State of Florida ­ Civil Division Case No. PLAINTIFF, VS DEFENDANT. _______________________________________/ FACT INFORMATION SHEET ­ INDIVIDUAL FULL LEGAL NAME:_____________________________________________________ NICKNAMES OR ALIASES: _______________________________________________ RESIDENCE ADDRESS: __________________________________________________ MAILING ADDRESS (IF DIFFERENT): _____________________________________ TELEPHONE NUMBERS: (HOME): _________________ (BUSINESS): ___________ NAME OF EMPLOYER: __________________________________________________ ADDRESS OF EMPLOYER:_______________________________________________ POSITION OR JOB DESCRIPTION: ________________________________________ RATE OF PAY: $_________ PER ____________. AVERAGE PAYCHECK $_______ PER __________ AVERAGE COMMISSIONS OR BONUSES: $_________ PER ________. COMMISSIONS OR BONUSES ARE BASED ON _____________________________ OTHER PERSONAL INCOME: $_______________ FROM _____________________ (EXPLAIN DETAILS ON THE BACK OF THIS SHEET OR ADDITIONAL SHEET IF NECESSARY) SOCIAL SECURITY NUMBER: ____________________ BIRTHDATE: ___________ DRIVER'S LICENSE NUMBER: ___________________________________________ MARITAL STATUS: __________________ SPOUSE'S NAME: __________________ SPOUSE'S ADDRESS (IF DIFFERENT): _____________________________________ SPOUSE'S SOCIAL SECURITY NUMBER: ___________BIRTHDATE: ___________ SPOUSE'S EMPLOYER: __________________________________________________ SPOUSE'S AVERAGE PAYCHECK OR INCOME: $_______________ PER ________ OTHER FAMILY INCOME: $______________ PER _____________________ (EXPLAIN DETAILS ON BACK OF THIS SHEET OR AN ADDITIONAL SHEET IF NECESSARY) NAMES AND AGES OF ALL YOUR CHILDREN (AND ADDRESSES IF NOT LIVING WITH YOU): __________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________ CHILD SUPPORT OR ALIMONY PAID $____________ PER ____________________ NAMES OF OTHERS YOU LIVE WITH: _____________________________________ Revised 7/1/2012 ________________________________________________________________________ WHO IS HEAD OF YOUR HOUSEHOLD? ___ YOU ______ SPOUSE ______ OTHER PERSON CHECKING ACCOUNT AT: _____________________ ACCOUNT #______________ SAVINGS ACCOUNT AT: _______________________ACCOUNT #______________ (DESCRIBED ALL OTHER ACCOUNTS OR INVESTMENTS YOU MAY HAVE, INCLUDING STOCKS, MUTUAL FUNDS, SAVINGS BONDS OR ANNUITIES, ON THE BACK OF THIS SHEET OR AN ADDITIONAL SHEET IF NECESSARY) FOR REAL ESTATE (LAND) YOU OWN OR ARE BUYING: ADDRESS: _____________________________________________________________ ALL NAMES ON TITLE: __________________________________________________ MORTGAGE OWED TO: _________________________________________________ BALANCE OWED: _______________________________________________________ MONTHLY PAYMENT: $_________________________________________ (ATTACH A COPY OF THE DEED OR MORTGAGE, OR LIST THE LEGAL DESCRIPTION OF THE PROPERTY ON THE BACK OF THIS SHEET OR AN ADDITIONAL SHEET IF NECESSARY. ALSO PROVIDE THE SAME INFORMATION ON ANY OTHER PROPERTY YOU OWN OR ARE BUYING) FOR ALL MOTOR VEHICLES YOU OWN OR ARE BUYING: YEAR/MAKE/MODEL: ______________________________ COLOR: _____________ VEHICLE ID #: _________________ TAG NO: ___________ MILEAGE: __________ NAMES ON TITLE: ____________________________ PRESENT VALUE: _________ LOAN OWED TO:________________________________________________________ BALANCE ON LOAN: $___________________________________________________ MONTHLY PAYMENT: $________________ LIST ALL OTHER AUTOMOBILES, AS WELL AS OTHER VEHICLES, SUCH AS BOATS, MOTORCYCLES, BICYCLES OR AIRCRAFT, ON THE BACK OF THIS SHEET OR AN ADDITIONAL SHEET IF NECESSARY.) __________________________________________________________________________________ ______________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________ HAVE YOU GIVEN, SOLD, LOANED OR TRANSFERRED AN REAL OR PERSONAL PROPERTY WORTH MORE THAN $100 TO ANY PERSON IN THE LAST YEAR? IF YOU ANSWER IS "YES", DESCRIBE THE PROPERTY AND SALE PRICE, AND GIVE THE NAME AND ADDRESS OF THE PERSON WHO RECEIVED THE PROPERTY: _____________________________________________ _______________________________________________________________________ _______________________________________________________________________ DOES ANYONE OWE YOU MONEY? AMOUNT OWED: $____________________ NAME AND ADDRESS OF PERSON OWING MONEY:________________________ ________________________________________________________________________ REASON MONEY IS OWED: ______________________________________________ PLEASE ATTACH COPIES OF THE FOLLOWING: A. YOUR LAST PAY STUB B. YOUR LAST 3 STATEMENTS FOR EACH BANK, SAVINGS, CREDIT UNION OR OTHER FINANCIAL ACCOUNT. Revised 7/1/2012 C. D. YOUR MOTOR VEHICLE REGISTRATIONS AND TITLES ANY DEEDS OR TITLES TO ANY REAL OR PERSONAL PROPERTY YOU OWN OR ARE BUYING OR LEASES TO PROPERTY YOU ARE RENTING. UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWER ARE TRUE AND COMPLETE. ____________________________________ JUDGMENT DEBTOR STATE OF FLORIDA COUNTY OF ST. LUCIE THE FOREGOING INSTRUMENT WAS ACKNOWLEDGED BEFORE ME ON _____________________________________, BY ____________________________________ WHO IS PERSONALLY KNOWN TO ME OR HAS PRODUCED ________________________ AS IDENTIFICATION AND WHO _____ DID/DID NOT _____ TAKE AN OATH. WITNESS MY HAND AND OFFICIAL SEAL ON ________________________________ __________________________________________ NOTARY PUBLIC STATE OF FLORIDA MY COMMISSION EXPIRES: _____________________ MAIL OR DELIVER THE COMPLETED FORM TO THE JUDGMENT CREDITOR OR THE CREDITOR'S ATTORNEY. DO NOT FILE A COPY OF THIS FORM WITH THE COURT. Revised 7/1/2012 merican Legae,t cn.I A lN .omwFrsW.cokFmrlw