Fact Information Sheet Business {SC 124}

SC 124 (Rev. 6/2011 per update to Small Claims Rules) SC 124 5/06 COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION UCN: Reference No.: Plaintiff(s), FACT INFORMATION SHEET vs 227 BUSINESS ENTITY Defendant(s), Name/Title of person filling out this form: Address: Telephone Number: Home: Business: Address of Business Entity: Type of Entity: (Check One) Corporation Partnership Limited Partnership Sole Proprietorship Limited Liability Corporation (LLC) Professional Association (PA) Other: (Please Explain) Does Business Entity own/have interest in any other business entity? If so please explain. Gross/Taxable income reported for Federal Income Tax purposes last three years: $ $ $ Taxpayer Identification Number: List Partners (General or Limited and Designate Percentage of Ownership): Average No. of Employees/Month: Names of Officers and Directors: Checking Account at: Account No: Savings Account At: Account No: Does the Business Entity own any vehicles: Years/Makes/Models: Vehicle I.D. Nos.: Tag Nos.: Loans Outstanding: Does the Business Entity own any real property: YES NO If Yes: Address: Please check if the business entity owns the following: Boat Camper Stocks/Bonds Other Real Property Other Personal Property Intangible Property Please attach copies of the following: 1. All tax returns for the past 3 years, including but not limited to state and federal income tax returns and tangible personal property tax returns. 2. All bank, savings and loan, and other account books or statements for accounts in institutions in which the defendant had any legal or equitable interest for the past 3 years. 3. All canceled checks for the 12 months immediately preceding the date of this judgment for accounts in which the defendant held any legal or equitable interest. 4. All deeds, leases, mortgages, or other written instruments evidencing any interest in or ownership of real property at any time within the 12 months immediately preceding the date of this judgment. American LegalNet, Inc. www.FormsWorkFlow.com SC 124 (Rev. 6/2011 per update to Small Claims Rules) SC 124 5/06 5. Bills of sale or other written evidence of the gift, sale, purchase, or other transfer of any personal or real property to or from the defendant within the 12 months immediately preceding the date of filing this lawsuit. Any transfer of property within the last year other than ordinary course of business transactions. 6. Motor vehicle documents, including titles and registrations relating to any motor vehicles owned by the defendant alone or with others. 7. Financial statements and any other business records, including but not limited to accounts payable and accounts receivable ledgers, as to the defendant222s assets and liabilities prepared within the 12 months immediately preceding the date of this judgment. 8. Copies of articles, by-laws, partnership agreement, operating agreement, and any other governing documents, and minutes of all meetings of the defendant222s shareholders, board of directors, or members held within 2 years of the date of this judgment. 9. Resolutions of the shareholders, board of directors, or members passed within 2 years of the date of this judgment. 10. A list or schedule of all inventory and equipment. UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE TRUE AND COMPLETE. Defendant222s Designated Representative Title: STATE OF FLORIDA COUNTY OF The foregoing instrument was acknowledged before me on (date), by , as the defendant222s duly authorized representative, who is personally known to me or has produced as identification and who did/did not take an oath. WITNESS my hand and official seal, on (date). Notary Public State of Florida My Commission expires: MAIL OR DELIVER THE COMPLETED FORM TO THE JUDGMENT CREDITOR OR THE JUDGMENT CREDITOR222S ATTORNEY. DO NOT FILE THIS FORM WITH THE COURT. American LegalNet, Inc. www.FormsWorkFlow.com