COUNTY COURT, PINELLAS COUNTY, FLORIDA
SMALL CLAIMS DIVISION
UCN: Reference No.:
vs. Defendant 1
Plaintiff(s)
Defendant 2
Defendant(s)
Address: Address:
STATEMENT OF CLAIM
Plaintiff(s) sue(s) the Defendant(s) for damages which do not exceed $8,000.00 exclusive of
costs, interest and attorney’s fee for (check one category below):
( ) Auto Accident
( ) Bad Check - Select one: ( ) insufficient funds ( ) stop payment ( ) other
( ) Breach of Agreement - Select one: ( ) oral agreement ( ) written agreement
Select one:
( ) Goods or merchandise – Select one: ( ) sold by Plaintiff ( ) received by Plaintiff
( ) Money paid for either goods or services not provided
( ) Services including materials – Select one: ( ) rendered by Plaintiff ( ) received by Plaintiff
( ) Wages including salary, commission or fees
( ) Mone
y loaned - Select one ( ) oral loan ( ) written loan
( ) Rent/Property Da
mage - Select one ( ) oral lease ( ) written lease
Amount claimed for Rent: ___________ Amount claimed for Property Damage:
( ) Security
Deposit c
laim
( ) Other cl
aim – Please specify: ________________________________________________________
Explain below the details (what happened, dates, times, place, etc) of your claim. This sect
ion must be
completed.
( ) Attached is a copy of any written document(s) that is the basis of this claim.
WHEREFORE, the Plaintiff(s) demand judgment in the principal sum of $
plus costs in the amount of $
plus interest in the amount of $
plus attorney’s fee in the amount of $
Under penalties of perjury, I / We declare that I / We have read the foregoing statement of claim, that
the facts stated in it are true, and that Defendant(s) is/are not in the military service of the United States.
Signature of Attorney for Plaintiff(s) Signature of all Plaintiff(s) or Company Representative
Plaintiff or Attorney Address:
Print name of all Plaintiff(s) or Company Representative
Title (if applicable)
Telephone No. Atty Telephone No.
Atty SPN No.
SC 002 (Revised 12/19)
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