Form Clk/ct. 175 - Statement Of Claim (For Work Done And Materials Furnished) Page 2

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RECEIPT NUMBER

SERVICE OF PROCESS

FILING FEE AMOUNT

PROCESS SERVER

SHERIFF

MAIL

NOTE:

If the claim is based upon a written document, a copy, or the material part thereof, shall be attached to the statement of claim.

INSTRUCTION SHEET

IMPORTANT

YOU MUST advise the Clerk, in writing, of any change in your mailing address.

If you are a DEFENDANT and fail to appear on the designated date, in person or by an attorney, a judgment may be entered against you.

Plaintiff(s) will not be entitled to a default or judgment in the absence of an affidavit regarding the defendant’s military status in compliance with

applicable law. This form, if sworn to, will meet the above requirements.

If you are a PLAINTIFF and fail to appear on the designated date, in person or by an attorney, this case may be dismissed for Want of Prosecution.

Any claim of the Defendant against the Plaintiff, arising out of the same transaction or occurrence which is the subject matter of plaintiff’s claim, shall

be filed not less than 5 days prior to the appearance date, or within such times as the Court designates, When a counterclaim or set-off exceeds the

jurisdiction of the Court, it shall be filed in writing before or at the pretrial hearing, and the action shall then be transferred to the Court having jurisdiction

thereof. As evidence of good faith, the counter-claimant shall deposit a sum sufficient to pay the filing fee in the Court to which the case is to be

transferred with his counterclaim.

FAILURE TO MAKE THE DEPOSIT WAIVES THE RIGHT TO TRANSFER.

TRIAL BY JURY may be had upon written demand by Plaintiff made at the commencement of the action or by any defendant within 5 days after

service of the notice to appear or at the Pretrial Conference. If the demand is not made, the right to trial by jury is waived.

If at any time in the proceedings a settlement is reached between the parties, this office should be notified in writing by the Plaintiff.

If you have any questions regarding procedures, this office will assist you. This office cannot furnish legal advice to you. Please consult your attorney

for legal advice.

CAUTION

A copy of any paper that you file at any time with the Clerk or Judge MUST be sent by you to each attorney appearing in the case, if

any, or to all parties not represented by an attorney. You must set forth the date and to whom you sent the copy (or copies) of the

paper filed, which would be followed by your signature.

AMERICANS WITH DISABILITIES ACT OF 1990

ADA NOTICE

“If you are a person with a disability who needs any accommodation in order to

participate in this proceeding, you are entitled, at no cost to you, to the provision of

certain assistance. Please contact the Eleventh Judicial Circuit Court’s ADA

Coordinator, Lawson E. Thomas Courthouse Center, 175 NW 1

Ave., Suite 2702,