Affidavit Of Damages

IN THE COUNTY COURT IN AND FOR LEON COUNTY, FLORIDA CASE NO. __________________________________ Plaintiff vs. __________________________________ Defendant AFFIDAVIT OF DAMAGES STATE OF FLORIDA, COUNTY OF LEON. BEFORE ME, the undersigned authority, personally appeared _____________________________________, who being first duly sworn, says: 1. 2. 3. I am the [ ] Plaintiff or [ ] Plaintiff's agent in this case and am authorized to make this statement. This statement is based on my own personal knowledge. Defendant owes the Plaintiff the following amounts for the follow reasons: AMOUNTS $______________ $______________ $______________ $______________ $______________ TOTAL $______________ (attach additional page if necessary) Dated this _____ day of __________________, ______ _______________________________________ (Signature) __________________________________________ (Printed Name) REASONS _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ The foregoing instrument was acknowledged before me this _______ day of _________________, _______, by ______________________________, who is personally known to me or who has produced ___________________ as identification and who did [ ] did not [ ] take an oath. BOB INZER Clerk of the Court, Leon County By:__________________________________ Deputy Clerk/Notary ___________________________________ (Printed Name) Rev. 1/06 American LegalNet, Inc. www.FormsWorkflow.com