SECOND JUDGMENT LIEN CERTIFICATE FOR PURPOSES OF FILING A SECOND JUDGMENT LIEN, THE FOLLOWING INFORMATION IS SUBMITTED IN ACCORDANCE WITH s. 55.204, FLORIDA STATUTES. THIS SECOND JUDGMENT LIEN IS A NEW LIEN AND NOT A CONTINUATION OF THE ORIGINAL LIEN. 1. __________________________________________________________________________________________ FILE NUMBER ASSIGNED TO THE RECORD OF THE ORIGINAL JUDGMENT LIEN CERTIFICATE: DO NOT PHOTOCOPY THIS FORM PRIOR TO USE. BAR CODE MUST BE LEGIBLE. 2. DATE FILED WITH DEPARTMENT OF STATE: ___________________________ ____________________ , MONTH DAY ____________ YEAR 3. JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF AN INDIVIDUAL, IS: ______________________________________________________________________ LAST NAME _____________________________________ FIRST NAME _________ M. I. ________________________________________________________________________________________________________________________ MAILING ADDRESS _______________________________________________________________________________________ CITY __________ ST ___________________ ZIP 4. ADDITIONAL JUDGMENT DEBTOR, IF AN INDIVIDUAL, IS: _______________________________________________________________________ LAST NAME _____________________________________ FIRST NAME ________ M.I. ________________________________________________________________________________________________________________________ MAILING ADDRESS ______________________________________________________________________________________ CITY __________ ST ____________________ ZIP 5. JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF A BUSINESS ENTITY, IS: ________________________________________________________________________________________________________________________ BUSINESS ENTITY NAME ________________________________________________________________________________________________________________________ MAILING ADDRESS ______________________________________________________________________________________ CITY __________ ST ____________________ ZIP 6. FEDERAL EMPLOYER IDENTIFICATION NUMBER: _________________________________________________________________ 7. DEPARTMENT OF STATE DOCUMENT FILE NUMBER: ______________________________________________________________ PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE 8. JUDGMENT CREDITOR (PLAINTIFF) NAME AS SHOWN ON JUDGMENT OR CURRENT OWNER OF JUDGMENT, IF ASSIGNED: __________________________________________________________________________________________ CREDITOR NAME (S) THIS SPACE FOR USE BY FILING OFFICER __________________________________________________________________________________________ MAILING ADDRESS 11. AMOUNT REMAINING UNPAID: $________________________________ _______________________________________________________________ ________ _______________ 9. ST ZIP DEPARTMENT OF STATE DOCUMENT FILE NUMBER: ______________________________________________________________ PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE CITY APPLICABLE INTEREST RATE: __________________________________ INTEREST ACCRUED AMOUNT: $________________________________ 12. NAME OF COURT: 10. OWNER'S ATTORNEY OR AUTHORIZED REPRESENTATIVE: (ACKNOWLEDGMENT OF THIS FILING WILL BE SENT TO THIS ADDRESS) ________________________________________________________________ _________________________________________________________________________________________ NAME ________________________________________________________________ _________________________________________________________________________________________ MAILING ADDRESS 13. CASE NUMBER: _______________________________________________ ______________________________________________________________ _________ ______________ CITY ST ZIP 14. DATE OF ENTRY: _______________ ____________, _____________ MONTH DAY YEAR 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; and, (3) 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 CERTIFIED COPY REQUESTED $ 10.00 Division of Corporations · P.O. Box 6250 · Tallahassee, Fl 32314 · 850-656-7463 CR2E092 (3/08) American LegalNet, Inc. www.FormsWorkflow.com