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IN THE COUNTY COURT, IN AND FOR PINELLAS (Pinellas County Clerk of the Circuit Court and Comptroller)

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IN THE COUNTY COURT, IN AND FOR PINELLAS COUNTY, FLORIDA
SMALL CLAIMS COURT
UCN: ______________________________ Reference No.: ______________________________
_____________________________________
_____________________________________
Plaintiff(s)
vs.
_____________________________________
_____________________________________
Defendant(s)
SWORN STATEMENT OF COURT COSTS AND/OR INTEREST
I have incurred the following costs and/or am entitled to the following amount of interest in this matter:
Court Costs:
Filing Fee __________________________
Service of Process Fee _________________________________
Interest:
Amount ____________________
Calculated Since ____________________________________
Rate ___________________________
Basis ____________________________________________________________________________________________
__________________________________________________________________________________________________
Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.
_______________________________________
Signature of Plaintiff
_______________________________________
Date of Signature
SC 121 (Rev. 1/1/03)
SC 121 12/02
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IN THE COUNTY COURT, IN AND FOR PINELLAS (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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