COUNTY COURT, PINELLAS COUNTY, FLORIDA
SMALL CLAIMS DIVISION
UCN: Reference No.:
Address: Plaintiff(s)/Counter Defendant (s)
vs.
Address: Defendant(s)/Counter Plaintiff(s)
STATEMENT OF COUNTER CLAIM
Defendant(s)/Counter Plaintiff(s) sue(s) the Plaintiff(s)/Counter Defendant (s) for damages which do
not exceed $8,000.00 exclusive of costs, interest and attorney’s fee for (check one category below):
( ) Auto Accident
( ) Bad Check - Select one: ( ) insufficient funds ( ) stop payment ( ) other
( ) Breach of Agreement - Select one: ( ) oral agreement ( ) written agreement
Select one:
( ) Goods or merchandise – Select one: ( ) sold by Plaintiff ( ) received by Plaintiff
( ) Money paid for either goods or services not provided
( ) Services including materials – Select one: ( ) rende
red by Plaintiff ( ) received by Pla
intiff
( ) Wages including salary, commission or fees
( ) Mone
y loaned - Select one ( ) oral loan ( ) written loan
( ) Rent/Property Damage - Select one ( ) oral l
ease ( ) written lease
Amount claimed for Rent: _______________ Amount claimed for Property Damage: ______________
( ) Securit
y Deposit
claim
( ) Other claim – Please spec
ify: _________________________________________________________________
Explain below the details (what happened, dates, times, place, etc) of your claim. This section must be completed.
( ) Attached is a copy of any written document(s) that is the basis of this claim.
WHEREFORE, the Defendant(s)/Counter Plaintiff(s) demand judgment in the principal
sum of $
plus costs in the amount of $
plus interest in the amount of $
plus attorney’s fee in the amount of $
I / We certify that I / We have mailed/hand-delivered to the Plaintiff(s)/Counter Defendant (s) a copy of this
counter claim this date.
Under penalties of perjury, I / We declare that I / We have read the foregoing statement of counter claim, that the
facts stated in it are true, and that Plaintiff(s)/Counter Defendant (s) is/are not in the military service of the United
States.
Signature of Attorney for Defendant(s)/Counter
Plaintiff(s)
Signature of all Defendant(s)/Counter Plaintiff(s) or
Company Representative
Address:
Print name of all Defendant(s)/Counter Plaintiff(s) or
Company Representative
Title (if applicable)
Telephone No.
SPN No.
Telephone No.
SC 076 (Revised 01/2020)
