Form Clk/ct. 795 - Statement Of Claim (For Money Lent)
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IN THE COUNTY COURT IN AND FOR MIAMI-DADE COUNTY, FLORIDA.
CASE NUMBER
DIVISION
STATEMENT OF CLAIM
CIVIL
(FOR MONEY LENT)
DISTRICTS
(File in Duplicate Plus One For Each Defendant)
SECTION NO.
OTHER
PLAINTIFF
VS.
DEFENDANT(S)
CLOCK IN
The Plaintiff sues the Defendant for money
Address:
Phone Number:
owed Plaintiff by Defendant; and which is past
due and unpaid; for (As marked (x) below):
Money lent by plaintiff to defendant which is due and payable;
Other (Explain)
Plaintiff(s), _________________________________________________, sues defendant(s), _____________________________
___________________________________________________________, and alleges: There is now due, owing, and unpaid from
defendant to plaintiff $ _______________ for money lent by plaintiff(s) to defendant(s) on ________________________ 20_____,
with interest thereon since _________________________, 20_____.
Where Plaintiff demands judgment in the sum of $ ________________ together with court costs and any further costs which the
Court may assess.
The Plaintiff, ________________________________________ says the foregoing is a just and true statement of the amount owed
by defendant to plaintiff, exclusive of all lawful setoffs, and that defendant has no lawful defenses which would preclude the
collection of said amount.
Affiant states that the defendant(s) is/are not in the military service of the United States.
Attorney/Plaintiff
Signature
Attorney’s Bar No.
Address of Attorney/Plaintiff
Telephone No.
The foregoing instrument was acknowledged before me this ___________ day of ___________________________, 20____ by
____________________________ who is personally known to me or who has produced _____________________ as identification
and did
/ did not
take an oath.
SWORN TO AND SUBSCRIBED BEFORE ME this ______ day of __________________________ 20_____.
NOTARY PUBLIC,
HARVEY RUVIN
State of Florida _____________________
CLERK OF COURTS
_________________________________
Deputy Clerk
My Commission Expires:
IMPORTANT: SEE REVERSE
PRINT
SAVE
RESET
CLK/CT. 795 Rev. 06/11
Clerk’s web address:
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