SC 104 (Rev. 6/2011 per update to Small Claims Rules) SC104 12/02
COUNTY COURT, PINELLAS COUNTY, FLORIDA
SMALL CLAIMS DIVISION
UCN:
Reference No.:
Plaintiff(s),
FACT INFORMATION SHEET
vs
INDIVIDUAL
Defendant(s),
Full Legal Name:
Nicknames or Aliases:
Residence Address:
Mailing Address (if different):
Telephone Numbers: (Home) (Business)
Name of Employer:
Address of Employer:
Position or Job Description:
Rate of Pay: $ per . Average Paycheck: $ per
Average Commissions or Bonuses: $ per . Commissions or bonuses are
based on
Other Personal Income: $ from
(Explain details on the back of this sheet or an additional sheet if necessary.)
Social Security Number: Birthdate:
Driver’s License Number:
Marital Status: Spouse’s Name:
Spouse’s Address (if different):
Spouse’s Social Security Number: Birthdate:
Spouse’s Employer:
Spouse’s Average Paycheck or Income: $ per
Other Family Income: $ per (Explain details on back of this sheet or an
additional sheet if necessary.)
Names and Ages of All Your Children (and addresses if not living with you):
Child Support or Alimony Paid: $ per
Names of Others You Live With:
Who is Head of Your Household? You Spouse Other Person
Checking Account at: Account #
Savings Account at: Account #
(Describe all other accounts or investments you may have, including stocks, mutual funds, savings bonds, or
annuities, on the back of this sheet or an additional sheet if necessary.)
For Real Estate (land) You Own or Are Buying:
Address:
All Names on Title:
Mortgage Owed to:
Balance Owed:
Monthly Payment: $
(Attach a copy of the deed or mortgage, or list the legal description of the property on the back of this sheet
or an additional sheet if necessary. Also provide the same information on any other property you own or are
buying.)
SC 104 (Rev. 6/2011 per update to Small Claims Rules) SC104 12/02
For All Motor Vehicles You Own or Are Buying:
Year/Make/Model: Color:
Vehicle ID #: Tag No: Mileage:
Names on Title: Present Value: $
Loan Owed to:
Balance on Loan: $
Monthly Payment: $ (List all other automobiles, as well as other vehicles, such
as boats, motorcycles, bicycles, or aircraft, on the back of this sheet or an additional sheet if necessary.)
Have you given, sold, loaned, or transferred any real or personal property worth more than $100 to any
person in the last year?
If your answer is “yes,” describe the property and sale price, and
give the name and address of the person who received the property.
Does anyone owe you money? Amount Owed: $
Name and Address of Person Owing Money:
Reason money is owed:
Please attach copies of the following:
1. Your last pay stub.
2. Your last 3 statements for each bank, savings, credit union, or other financial account.
3. Your motor vehicle registrations and titles.
4. Any deeds or titles to any real or personal property you own or are buying, or leases to property you
are renting.
UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE
TRUE AND COMPLETE.
Judgment Debtor
STATE OF FLORIDA
COUNTY OF
The foregoing instrument was acknowledged before me on .(date), by
, 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.
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