IN THE COUNTY COURT OF THE FOURTH JUDICIAL CIRCUIT,
IN AND FOR CLAY COUNTY, FLORIDA
ACCURATE COMPLETION OF THIS STATEMENT IS NECESSARY SO THAT
THE CLERK CAN ASSIST YOU IN THE PREPARATION OF YOUR CLAIM
PLAINTIFF’S STATEMENT
Name of Plaintiff:
Address of Plaintiff:
Telephone number: Email Address:
Amount of Claim $
This claim is for: (Check the box that applies to your claim)
☐ Goods, ware, and merchandise sold by the Plaintiff(s) to the Defendant(s);
☐ Work done and materials furnished by the Plaintiff(s) to the Defendant(s);
☐ Money loaned by the Plaintiff(s) to the Defendant(s);
☐ Money due to the Plaintiff(s) upon accounts stated and agreed to between them;
☐ On a written instrument, copy of which is attached hereto;
☐ Rent for certain premises in Clay County, Florida;
☐ Other (Explain)
☐ Any additional facts in connection with any of the above:
Date when alleged debt or contract was incurred or damages occurred
Place where alleged debt or contract was incurred or damage occurred
If the defendant(s) is an individual, is he/she in the military service? ☐ Yes ☐ No
If the defendant(s) is not in the military service, are you prepared at this time to swear under oath to the
fact? ☐ Yes ☐ No
NOTE: (A) If you are suing an individual, give their full name
(B) If you are suing a business firm, give the firm name and the name of the owner
(C) If you are suing a partnership, you must name all of the partners
(D) If you are suing a corporation, give its full name, state where it is incorporated, and
names and addresses of its officers (President, Vice President, Secretary, and Treasurer)
(E) If your suit arises as a result of an automobile accident, you may name the driver, and
also the registered owner of the vehicle.
(F) If you are unable to determine which of the above applies to your case, please see the
Clerk.
My Claim is against (Name and Address of Defendant(s))
Plaintiff(s) or Agent
