INSTRUCTIONS FOR
STATEMENT OF CLAIM
A Statement of Claim is the form used to file a Small Claims case for monetary purposes only. You must
have a complete name and address of the person(s) being sued. A brief explanation us required
and any supporting documents are to be attached. A pre-trial date will be set and you will need to appear
at that time along with the defendant for the judge to hear your case. If you are awarded a Judgment,
the Judge will add all costs incurred in filing the case. These costs need not be included in your claim.
This form is accompanied by a Plaintiff’s Statement.
Contact the Civil Law Department at (904) 284/269-6363 if you have any questions regarding
completing this form.
IN THE COUNTY COURT
IN AND FOR
CLAY COUNTY, FLORIDA
Plaintiff
CASE NO.
-VS -
Defendant
STATEMENT OF CLAIM
Plaintiff, , sues defendant
, and alleges and says:
Plaintiff
THE AMOUNT OF THIS CLAIM IS $
WHEREFORE, Plaintiff demands judgment for damages against defendant
DO NOT WRITE ON THE BACK OF THIS FORM. IF YOU NEED ADDITIONAL SPACE, PLEASE
CONTINUE ON A SEPARATE SHEET OF PAPER.