Proof Of Claim

IN THE COUNTY COURT IN AND FOR DUVAL COUNTY, FLORIDA CASE NUMBER: DIVISION: ________________________________ (Plaintiff) VS. _________________________________ (Defendant) Proof of Claim STATE OF FLORIDA COUNTY OF DUVAL Before me, the undersigned authority, personally appeared _____________________________ ____________________________ who, being first dully sworn, deposes and says; that he (she)(they) is (are) the Plaintiff(s) or Plaintiff's agent named in the Statement of Claim filed herein; that the balance due to the plaintiff(s) from the Defendant(s) is the sum of $______________________ , plus court costs, which is a trust and correct statement of the account as of _____________________________________ and that no set-offs exist. This action has been brought in Duval County where venue is proper. At Jacksonville, Florida this ________________ day of ________________, _______________. __________________________________ (Signature) SWORN TO AND SUBSCRIBED BEFORE ME THIS ________ DAY OF _______ , ________. ________________________ ___________ (Title) RONNIE FUSSELL CLERK OF THE CIRCUIT AND COUNTY COURT DUVAL COUNTY, FLORIDA BY: ___________________________________ DEPUTY CLERK American LegalNet, Inc. www.FormsWorkFlow.com