COUNTY COURT, PINELLAS COUNTY, FLORIDA
SMALL CLAIMS DIVISION
UCN: ______________________________ Reference No.: ______________________________
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Address: Plaintiff(s)
vs.
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Address: Defendant(s)
STATEMENT OF CLAIM - AUTO ACCIDENT
Plaintiff(s) sue(s) the Defendant(s) for damages which do not exceed $8,000.00, exclusive of costs,
interest and attorney’s fee (if appropriate) and allege(s):
1. On _________________________ , 20 ___ , Defendant(s) owned and/or operated a motor vehicle at
____________________________________________________________ , Pinellas County, Florida.
(place)
2. At the time, the Defendant(s) negligently operated or maintained the motor vehicle so that a collision
occurred between Plaintiff(s) _________________________________________________________
and Defendant(s) motor vehicle.
3.
As a result, Plaintiff(s), was/were injured and/or sustained damages to his/their motor vehicle/property.
4. Plaintiff(s) automobile is a ____________________________________________________________
(year, make, model of automobile)
WHEREFORE, Plaintiff(s) demand judgment in the principal amount of $ _____________________
determined as follows:
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together with costs, interest and attorney’s fee.
STATE OF FLORIDA :
COUNTY OF PINELLAS: ss.
Plaintiff ____________________________________________________________________________
(Please print Plaintiff’s/Plaintiffs’ name exactly as it appears at top of form.) states/state that the foregoing is a just
and true statement of the amount owed by Defendant(s) to Plaintiff(s) exclusive of all set-offs and just grounds of defense.
Affiant states that Defendant(s) is/are not in the military service of the United States.
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Signature of Attorney for Plaintiff(s) Signature of all Plaintiff(s) or Company Representative
Address: _ _ _ _ _ _ _ _ ____________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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Telephone No. _ _ _ _ _ _ _______________________________
SPN No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Auto Accident
SC 056 (Rev. 01/2020)
(motor vehicle or property)Pr
Print name of all Plaintiff(s) or Company Representative
Telephone No. _____________________________
___________________________________________________
Title (if applicable)
