Form Sc 057 - Statement Of Claim - Landlord/tenant - Damages To Premises And Unpaid Rent - County Court, Pinellas County, Florida

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COUNTY COURT, PINELLAS COUNTY, FLORIDA

SMALL CLAIMS DIVISION

UCN: ______________________________ Reference No.: ______________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address:

Plaintiff(s)

vs.

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Address:

Defendant(s)

STATEMENT OF CLAIM

LANDLORD/TENANT - DAMAGES TO PREMISES AND UNPAID RENT

Plaintiff(s) sue(s) the Defendant(s) for damages which do not exceed $5,000.00, exclusive of costs, interest and attorney's fee

(if appropriate) and allege(s):

COUNT I

1. On or about , ___________________________ , ___________ , Plaintiff(s), Landlord(s), leased to Defendant(s), Tenant(s), premises

located at _______________________________________________________________________________________ , Pinellas County, Florida.

2. The lease was an oral lease containing the following provisions:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Set out length of lease in months or years; amount of rent payment; the notice requirement for vacating the premises; amount of security deposit; and,

the amount of prepaid last month's rent, if any.)

— OR —

(A copy of the written lease is attached.)

3. Defendant(s) vacated the premises on or about __________________________________________________________ , ________ .

4. Defendant(s) left damages in the amount of $ ____________________________ , as follows:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

item

amount

Item

amount

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

$ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

item

amount

Item

amount

WHEREFORE, Plaintiff(s) demand judgment in the sum of $ ______________________ , together with costs, interest, and attorney’s fee.

COUNT II

1. On or about _______________________________ , Plaintiff(s), Landlord(s), leased to the Defendant(s), Tenant(s), premises located

at _____________________________________________________________________________________ Pinellas County, Florida.

2. The lease was an oral lease containing the provisions as set out in paragraph 2 of Count I of this Statement of Claim.

— OR —

(A copy of the written lease is attached.)

3. Defendant(s) failed to pay rent for the period of ____________________________________________ , leaving rent due and owing of

$ ________________________________ .

4. Defendant(s) vacated the premises on or about ____________________________________________________________ .

WHEREFORE, Plaintiff(s) demand judgment in the principal sum of $ ________________________ plus costs, interest and attorney's fee.

STATE OF FLORIDA

ss.

COUNTY OF PINELLAS:

Plaintiff ________________________________________________________________________________________________

(Please print Plaintiff’s/Plaintiffs’ name exactly as it appears at top of form.) states/state that the foregoing is a just and true statement of the amount owed by

Defendant(s) to Plaintiff(s) exclusive of all set-offs and just grounds of defense. Affiant states that Defendant(s) is/are not in the military service of the United States.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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Signature of Attorney for Plaintiff(s)

Signature of Plaintiff(s) or Company Representative

Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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Print name of all Plaintiff's or Co. Representative / Title

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Telephone No. ___________________________________

Telephone No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

SPN No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Landlord/Tenant - Damages

to Premises and Unpaid Rent

SC 057 (Rev. 9/24/08)

SC 057

9/24/08