Florida > Local County > Santa Rosa > Civil-Small Claims
Statement Of Claim - Florida
| Statement Of Claim Form. This is a Florida form and can be used in Civil-Small Claims Santa Rosa Local County . |
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IN THE COUNTY COURT IN AND FOR SANTA ROSA COUNTY, FLORIDA SMALL CLA IMS DI VI SI ON PLAIN TIFF(S): ADDRE SS: TELEPHONE: VS CASE NO: DEFEND ANT(S) ADDRE SS: TELEPHONE: STA TE ME NT OF CLAIM PLAINTIFF(S) CLAIMS THE AM OUNT OF $ AS BEI NG DUE FROM THE DEFENDANT(S) TOGETHER WITH $ 0 FOR INTERE ST PLUS CO URT CO STS AND SE RVICE FEES OF $ WHICH ALL TOT ALS $ , AND ALLEGES TH AT TH E BASIS OF THIS SUIT IS: Money due plaintiff upon accounts stated and agreed to between them. Money loaned by plaintiff to defendant. Goods, wares, and merchandise sold by plaintiff to defendant. Rent due plaintiff for certain premises in Santa Rosa County, Florida. Defective goods/workmanship/services furnished to plaintiff by defendant. (List goods and describe defects below) Damages due to auto collision. (Describe below Defendants negligent act which caused collision.) Plaintiff further states the suit is based on a written instrument. Money due plaintiff for worthless check given by defendant. Money due plaintiff for labor and materials furnished to defendant. Other: STATE OF FLORIDA COUNTY OF SANTA ROSA THE UNDER SIGNED, BEIN G DULY S WORN, S AYS THA T THE FORE GOING IS A J UST AND TR UE STATE MENT OF THE AM OUNT OWING BY T HE DEFE NDAN T(S) TO SAID PLAINTIFF(S) EXCLUSIVE OF ALL SET-OFFS AND JUSTGROUNDS OF DEFENSE: SWORN AND SUBSCRIBED BEFORE ME this day of , 20 Plaintiff(s) By: Deputy Clerk or Notary NOTICE: THIS DOCUMENT REQUIRES AN OFFIC IAL COURT SU MMONS WITH SIGNATURE AND THE OFFICIAL COURT MARY M. JOHNSON, CLERK OF COURTS SEAL AFFIXED THE RETO. SMALL CLAIM DIVISION-COUNTY COURT
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