JUDGMENT LIEN CERTIFICATE FOR PURPOSES OF FILING A JUDGMENT LIEN, THE FOLLOWING INFORMATION IS SUBMITTED IN ACCORDANCE WITH s. 55.203, FLORIDA STATUTES. 1. JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF AN INDIVIDUAL, IS: DO NOT PHOTOCOPY THIS FORM PRIOR TO USE. BAR CODE MUST BE LEGIBLE. ___________________________________________ __________________________________ _______ LAST NAME FIRST NAME M. I. ________________________________________________________________________________________ MAILING ADDRESS _____________________________________________________ _____________ __________________ CITY ST ZIP 2. ADDITIONAL JUDGMENT DEBTOR, IF AN INDIVIDUAL, IS: ___________________________________________ __________________________________ _______ LAST NAME FIRST NAME M. I. ________________________________________________________________________________________ MAILING ADDRESS _____________________________________________________ _____________ __________________ CITY ST ZIP 3. JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF A BUSINESS ENTITY, IS: ________________________________________________________________________________________ BUSINESS ENTITY NAME ________________________________________________________________________________________ MAILING ADDRESS _____________________________________________________ CITY ______________ ________________ ST ZIP 4. 5. FEDERAL EMPLOYER IDENTIFICATION NUMBER: _____________________________________________________ DEPARTMENT OF STATE DOCUMENT FILE NUMBER: ____________________________________________ PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE 6. JUDGMENT CREDITOR (PLAINTIFF) NAME AS SHOWN ON JUDGMENT OR CURRENT OWNER OF JUDGMENT, IF ASSIGNED: ______________________________________________________________________________________________________________________ CREDITOR NAME (S) ____________________________________________________________________________________________________ MAILING ADDRESS ______________________________________________________ _______________ _______________ CITY ST ZIP 7. DEPARTMENT OF STATE DOCUMENT FILE NUMBER: ____________________________________________ PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE THIS SPACE FOR USE BY FILING OFFICER 8. OWNER'S ATTORNEY OR AUTHORIZED REPRESENTATIVE: (ACKNOWLEDGMENT OF FILING WILL BE SENT TO THIS ADDRESS) 11. NAME OF COURT: ____________________________________________________________ ____________________________________________________________ ______________________________________________________________________________ NAME ________________________________________________________________________________________ MAILING ADDRESS 12. CASE NUMBER: ______________________________________________ 13. DATE OF ENTRY: ________________ MONTH ________ , ___________ DAY YEAR ______________________________________________________ ______________ ________________ CITY ST ZIP 9. AMOUNT DUE ON MONEY JUDGMENT: _______________________________________________________________ 10. APPLICABLE STATUTORY INTEREST RATE: ___________________________________________________________ UNDER PENALTY OF PERJURY, I hereby certify that: (1) The judgment above described has become final and there is no stay of the judgment or its enforcement in effect; (2) All of the information set forth above is true, correct, current and complete; (3) I have not previously filed a Judgment Lien Certificate regarding the above judgment with the Department of State; and, (4) I have complied with all applicable laws in submitting this Judgment Lien Certificate for filing. ______________________________________________________________________________________ SIGNATURE OF CREDITOR OR AUTHORIZED REPRESENTATIVE _______________________________________________________________________________ PRINT NAME NON-REFUNDABLE PROCESSING FEE: JUDGMENT LIEN WITH ONE DEBTOR $ 20.00 EACH ATTACHED PAGE, IF NECESSARY $ 5.00 EACH ADDITIONAL DEBTOR $ 5.00 (NO CHARGE FOR CREDITOR AFFIDAVIT) CERTIFIED COPY REQUESTED $10.00 Division of Corporations · P.O. Box 6250 · Tallahassee, Fl 32314 · 850-656-7463 CR2EO91 (04/08) American LegalNet, Inc. www.FormsWorkflow.com