Statement of Claim (Small Claims)

IN THE COUNTY COURT OF POLK COUNTY, FLORIDA CLAIMS DIVISION CASE NO. _______________________ ________________________________________________ ________________________________________________ ________________________________________________ Plaintiff(s), vs. ________________________________________________ ________________________________________________ ________________________________________________ Defendant(s). STATEMENT OF CLAIM The above named Plaintiff(s) sues the above named Defendant(s) , and alleges: WHEREFORE, Plaintiff(s) demands judgment in the sum of $______________plus all costs of this action. The undersigned, being by me first duly sworn, says that the foregoing is a just and true statement of the amount owing by the above named Defendant(s) to said Plaintiff(s), exclusive of all set offs and just grounds of defense, and that the action has been brought in the County in which venue is proper, pursuant to Chapter 47, Florida Statutes. Subscribed and sworn to before me this _____ day of ________________, A.D. ________. STACY M. BUTTERFIELD, Clerk of the Circuit Court By__________________________, D.C. or ___ ___ _______________________________________ Plaintiff Personally Known Produced Identification Type of identification presented: _______________ ________________________ _______________ Phone By__________________________, Notary Public My Commission Expires: STACY M. BUTTERFIELD Clerk of the Circuit Court American LegalNet, Inc. www.FormsWorkFlow.com