Fillable COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION (Pinellas County Clerk of the Circuit Court and Comptroller)

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COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION (Pinellas County Clerk of the Circuit Court and Comptroller)

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COUNTY COURT, PINELLAS COUNTY, FLORIDA
SMALL CLAIMS DIVISION
UCN: ______________________________ Reference No.: ______________________________
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Plaintiff(s)
VS.
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Defendant(s)
AFFIDAVIT
(Balance Due on Stipulation)
STATE OF FLORIDA :
COUNTY OF PINELLAS : ss.
Before me, the undersigned personally appeared _____________________________________________ ,
who, by me first duly sworn, states:
1. That he/she is the Plaintiff(s) who entered into the written stipulation filed in this cause.
2. That the Defendant(s) ________________________________________________________has failed to
make payment(s) pursuant to that agreement.
3. The last payment was made on _________________________________________________ , _________ .
4. The balance left due and owing under the agreement is $ ____________________________ principal and
$ _______________________________ costs.
WHEREFORE, Plaintiff (s) request the court to enter a Judgment for $ ______________________.
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Plaintiff(s)
SWORN TO AND SUBSCRIBED before me at ______________________________________________________ ,
this ___________________ day of ________________________________ , _________ .
________________________________________________
Deputy Clerk or Notary Public
State of Florida
My commission expires:
SC 034 (Rev. 1/1/03) SC034 12/02
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COUNTY COURT, PINELLAS COUNTY, FLORIDA SMALL CLAIMS DIVISION (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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