Form Clk/ct. 790 - Statement Of Claim (Auto Negligence)
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IN THE COUNTY COURT IN AND FOR MIAMI-DADE COUNTY, FLORIDA.
CASE NUMBER
DIVISION
STATEMENT OF CLAIM
CIVIL
(AUTO NEGLIGENCE)
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):
AUTO NEGLIGENCE
Any additional facts in connection with the above: (Use additional sheet if necessary)
The plaintiff sues the defendant and says: On or about _______________________________________________, in the vicinity of
_________________________________________________ , on a public highway in ______________________ County, Florida,
plaintiff’s motor vehicle, being operated by _________________________________________________, collided with defendant’s
motor vehicle, being operated by ____________________________________, and the collision with plaintiff’s vehicle was caused
by the negligent and careless operation of defendant’s vehicle, whereby plaintiff’s vehicle was damaged and depreciated in value.
(See Attached)
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. 790 Rev. 06/11
Clerk’s web address:
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