Affidavit (Balance Due On Stipulation) (Pinellas)

COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: ______________________________Reference No.: ______________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Plaintiff(s) VS. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Defendant(s) AFFIDAVIT (Balance Due on Stipulation) STATE OF FLORIDA : COUNTYOF PINELLAS : ss. Before me, the undersigned personally appeared _________________________ ____________________ , who, by me first duly sworn, states: 1. That he/she is the Plaintiff(s) who entered into the written stipulation filed in this cause. 2. That the Defendant(s) ________________________________________________ ________has failed to make payment(s) pursuant to that agreement. 3. The last payment was made on _________________________________________________ , _ ________ . 4. The balance left due and owing under the agreement is $ ____________________________ pr incipal and $ _______________________________ costs. WHEREFORE, Plaintiff (s) request the court to enter a Judgment for $ ____________________ __. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Plaintiff(s) SWORN TO AND SUBSCRIBED before me at ____________________________________________ __________ , this ___________________ day of ________________________________ , _____ ____ . ________________________________________________ Deputy Clerk or Notary Public State of Florida My commission expires: SC 034 (Rev. 1/1/03) SC034 12/02 American LegalNet, Inc. www.USCourtForms.com