Statement Of Claim

In The County Court Of The Seventh Judicial Circuit In And For Volusia County, Florida Number: Judge: STATEMENT OF CLAIM Sues Plaintiff(s) Address: Address: Defendant(s) Telephone: Telephone: This is an action for damages which do not exceed the sum of $5,000.00 exclusive of costs, interest and attorney's fees. Plaintiff(s) sues defendant(s) and alleges: (GIVE BRIEF STATEMENT EXPLAINING REASONS FOR FILING SUIT. Example: loan, accident, etc.) ** Please continue to next page if you have additional information. (If applicable a copy of the written instrument is attached hereto.) WHEREFORE, Plaintiff requests judgment in the amount of $ fees (if applicable) and costs of this action. STATE OF FLORIDA COUNTY OF VOLUSIA The above named Plaintiff being duly sworn states the foregoing claim is a just and true statement of the amount owing by the Defendant to the Plaintiff, exclusive of all setoffs and just grounds of defense. Plaintiff states that the Defendant is not in the Military Service of the United States. This action has been brought in the County in which venue is proper, pursuant to Chapter 47, Florida Statutes. damages, $ interest, attorney's Plaintiff or Plaintiff's Attorney Address: Telephone: CL-0219-1611 American LegalNet, Inc. www.FormsWorkFlow.com (USE THE REVERSE SIDE FOR ADDITIONAL CLAIM INFORMATION) (CONTINUATION OF STATEMENT OF CLAIM) FOR YOUR INFORMATION LAURA E. ROTH CLERK OF COURT 101 N Alabama Avenue DeLand, FL 32721-6043 386-736-5907 LAURA E. ROTH CLERK OF COURT 125 E. Orange Avenue Daytona Beach, FL 32115-2401 386-257-6081 LAURA E. ROTH CLERK OF COURT 124 N. Riverside Drive New Smyrna Beach, FL 32168 386-423-3304 **Mailing Address for Clerk of Court P.O. Box 6043 DeLand, FL 32721-6043 American LegalNet, Inc. www.FormsWorkFlow.com REQUESTS FOR ACCOMMODATIONS BY PERSONS WITH DISABILITIES If you are a person with a disability who needs an accommodation in order to participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact Court Administration, 125 E. Orange Ave., Ste. 300, Daytona Beach, FL 32114, (386) 257-6096, at least 7 days before your scheduled court appearance, or immediately upon receiving this notification if the time before the appearance is less than 7 days; if you are hearing or voice impaired, call 711. THESE ARE NOT COURT INFORMATION NUMBERS SOLICITUD DE ADAPTACIONES PARA PERSONAS CON DISCAPACIDADES Si usted es una persona con discapacidad que necesita una adaptación para poder participar en este procedimiento, usted tiene el derecho a que se le proporcione cierta asistencia, sin incurrir en gastos. Comuníquese con la Oficina de Administración Judicial (Court Administration), 125 E. Orange Ave., Ste. 300, Daytona Beach, FL 32114, (386) 257-6096, con no menos de 7 días de antelación de su cita de comparecencia ante el juez, o de inmediato al recibir esta notificación si la cita de comparecencia está dentro de un plazo menos de 7 días; si usted tiene una discapacidad del habla o del oído, llame al 711. ESTOS NUMEROS TELEFONICOS NO SON PARA OBTENER INFORMACION JUDICIAL American LegalNet, Inc. www.FormsWorkFlow.com