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Fact Information Sheet Small Claims Rules Law 390 - Florida
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IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA IN THE COUNTY COURT, BREVARD COUNTY, FLORIDA DIVISION CASE NUMBER FACT INFORMATION SHEET CIVIL SMALL CLAIMS RULES -- - - FORM 7.343 PLAINTIFF DEFENDANT CLOCK IN FULL LEGAL NAME NICK NAME OR ALIAS RESIDENCE ADDRESS MAILING ADDRESS HOME TELEPHONENUMBER BUSINESS NUMBER NAME OF EMPLOYER ADDRESS OF EMPLOYER POSTION OR JOB DESCRIPTION RATE OF PAY: $ PER . AVERAGE PAYCHECK: $ PER AVERAGE COMMISSIONS OR BONUS: $ PER . COMMISSIONSOR BONUES ARE BASED ON OTHER PERSONAL INCOME $ FROM . Explain details on the back of this sheet or an additional sheet if necessary.) SOCIAL SECURITY NO. BIRTHDATE DRIVERSLICENSE NO. MARTIAL STATUS SPOUSES NAME SPOUSES ADDRESS (if different) SPOUSES S.S.N. BIRTHDATE SPOUSES EMPLOYER: SPOUSES AVERAGE PAYCHECK OR INCOME: $ PER OTHER FAMILY INCOME $ PER (Explain details on back of this sheet or an additional sheeti fn ecessary) NAMES AND AGES OF ALL YOUR CHILDREN(andaddresses if not living with you:) CHILD SUPPORT OR ALIMONY PAID: $ PER NAMESO FO THERSY OU LIVE WITH: WHO IS HEAD OF YOUR HOUSEHOLD? YOU SPOUSE OTHER PERSON CHECKING ACCOUNT AT: ACCOUNT # SAVINGS ACCOUNT AT: ACCOUNT # Describe all other accounts or investments you may have, including stocks, mutualfunds, 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$. LAW 390 (REV. 02/2004) <<<<<<<<<********>>>>>>>>>>>>> 2 Page _____ of _____ PLAINTIFF DEFENDANT CASE NUMBER -- - -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 your own or are buying. FOR ALL MOTORV EHICLESY OU OWNO RA RE 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 any real or personal property worth more than $100 to any person in the last year? If you answer "yes", describe the property and sale price, and give the name of the address of the person who received the property. DOES ANYONE OWE YOU MONEY? AMOUNT OWED: $ NAME AND ADDRESS OF PERSON OWING MONEY: REASON MONEY 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. c. Your motor vehicle registrations and titles d. 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 answers are true and correct. Judgment Debtor STATE OF FLORIDA COUNTY OF BREVARD The foregoing instrument was acknowledged before me this day of , , by , who is personally known to me or has produced as identification and who did did not take an oath. Witnessmy hand and official seal, this day of , . NOTARY PUBLIC STATE OF FLORIDA My Commission Expires: LAW 390 (REV. 02/2004)
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