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
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.
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 defendant’s 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 defendant’s 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.
________________________________
Defendant’s Designated Representative
Title:
STATE OF FLORIDA
COUNTY OF
The foregoing instrument was acknowledged before me on (date),
by
, as the defendant’s 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
CREDITOR’S ATTORNEY
. DO NOT FILE THIS FORM WITH THE COURT.