Form Sc 046 - Statement Of Claim - Landlord/tenant - Security Deposit Refund - County Court, Pinellas County, Florida

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COUNTY COURT, PINELLAS COUNTY, FLORIDA

SMALL CLAIMS DIVISION

UCN: ______________________________ Reference No.: ______________________________

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Address:

Plaintiff(s)

vs.

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Address:

Defendant(s)

STATEMENT OF CLAIM - LANDLORD/TENANT - SECURITY DEPOSIT REFUND

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

(if appropriate) and allege(s):

1. On or about _________________________ , ________ , Plaintiff(s) lease _______________________________________located at

(an apartment/residence)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , Pinellas County, Florida, from Defendant(s).

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

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

(length of lease in months or years; amount of rent payment; amount of security deposit; amount of prepaid last month's rent,

if any; and any other provisions relevant to these proceedings.)

-OR-

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (a copy of the written lease is attached)

3. Plaintiff(s) vacated the premises on or about _______________________ , _______ .

4. Plaintiff(s) demanded return of (security deposit or last month's rent) by _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(in person request to - name and title of person - on whatever date; or by certified letter mailed to - name and title of person -

on whatever date; or by regular mail to - name and title of person on whatever date; or set out by whatever other method used).

5. Defendant(s) has/have refused to return the security deposit or last month's rent requested.

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

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.

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

Signature of Attorney for Plaintiff(s)

Signature of Plaintiff(s) or Company Representative

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

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

Print name of all Plaintiff(s) or Company Representative

Telephone No. ____________________________________

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

________________________________________________

Title (if applicable)

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

Landlord/Tenant - Security Deposit Refund

SC 046 (Rev. 9/24/08)

SC 046

9/24/08