SC 104 (Rev. 6/2011 per update to Small Claims Rules) SC104 12/02
For All Motor Vehicles You Own or Are Buying:
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
UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE
TRUE AND COMPLETE.
STATE OF FLORIDA
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
WITNESS my hand and official seal, on (date).
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.