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Statement Of Claim Law 167 - Florida
| Statement Of Claim Form. This is a Florida form and can be used in General Brevard Local County . |
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IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA IN THE COUNTY COURT, BREVARD COUNTY, FLORIDA DIVISION CIVIL CRIMINAL STATEMENT OF CLAIM JUVENILE TRAFFIC PLAINTIFF CASE NUMBER 05 - XXXX-XX BAR CODE LABEL CLOCK IN DEFENDANT PLAINTIFF'S ADDRESS & PHONE NO. DEFENDANT'S ADDRESS(ES) & PHONE NUMBER(S) The Plaintiff claims the amount of $________________ together with costs and attorney's fees, if applicable, as being due from the defendant and alleges as the basis of such suit the following matters: (Fill in the appropriate blanks) Goods sold and delivered by Plaintiff(s) to Defendant(s) between _________________________, 20_____, and _____________________, 20_____. Labor and materials furnished by Plaintiff(s) to Defendant(s) between _________________________, 20_____, and _____________________, 20_____. Money lent by Plaintiff(s) to Defendant(s) on or about _________________________, 20_____, with interest from ______________________, 20_____, in the amount of $_______________. On ______________________, 20_____, Defendant(s) executed and delivered to Plaintiff(s) a promissory note in ______________________________ County, Florida. Defendant(s) failed to pay said note when due, the installment payment due on said note on ______________________, 20_____, and Plaintiff(s) elected to accelerate payment of the balance. The balance now due, owing and unpaid is $_____________ plus interest since ______________________, 20_____, in the amount of $______________. On or about ______________________, 20_____, in the vicinity of ______________________________ on a public highway in ___________________________ County, Florida, Plaintiff's motor vehicle being operated by __________________________________ was in collision with Defendant's motor vehicle being operated by _________________________________, and that said collision with Plaintiff's vehicle was caused by the negligent and careless operation of Defendant's vehicle, whereby Plaintiff's vehicle was damaged and depreciated in value. Page 1 of 2 LAW 167 Rev. 02/2006 American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 2 PLAINTIFF STATEMENT OF CLAIM 05 - XXXX-XX CASE NUMBER Plaintiff(s) and Defendant(s) entered into a verbal/written rental agreement on ________________________, 20_____, for the property located at ______________________________, Brevard County, Florida. Defendant(s) vacated said property on or about _____________________, 20_____. Plaintiff is entitled to $_______________ which represents: [a] Rent due from ______________________, 20_____ to _______________________, 20_____. [b] Damages to said property in the amount of $_______________. [c] Damage Deposit which Defendant failed to return. Plaintiff is this filing complaint pursuant to F.S. 713.78(5)(a), to determine if property was wrongfully taken or withheld. Plaintiff has also posted a cash bond in the amount of $_____________, pursuant to F.S. 713.78(5)(b), in the amount equal to the lien claimed. WHEREFORE, Plaintiff demands judgment in the amount of $_______________, plus interest in the amount of $_______________, and applicable court costs and attorney's fees. STATE OF FLORIDA - COUNTY OF BREVARD ___________________________________ being duly sworn on oath states the foregoing claim is a just and true statement of the amount owing by the defendant to the Plaintiff, exclusive of all set-offs and just grounds of defense. Plaintiff states that the Defendant(s) are not in the Military Service of the United States and that the above action has been brought in the County of proper venue. PLAINTIFF, ATTORNEY, OR CORPORATE AGENT DATE SWORN AND SUBSCRIBED TO BEFORE ME THIS __________ DAY OF ____________________, 20 _____. DEPUTY CLERK BREVARD COUNTY, FLORIDA THE FOREGOING INSTRUMENT WAS ACKNOWLEDGED BEFORE ME THIS _________ DAY OF __________, 20____, BY ________________________________________________________, WHO IS PERSONALLY KNOWN TO ME OR HAS PRODUCED ________________________________________________________________ AS IDENTIFICATION AND WHO DID (DID NOT) TAKE AN OATH. NOTARY PUBLIC LAW 167 Rev. 02/2006 American LegalNet, Inc. www.FormsWorkflow.com
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