Judgment Lien Certificate Template
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1DO NOT PHOTOCOPY THIS FORM PRIOR TO USE.
BAR CODE MUST BE LEGIBLE.
JUDGMENT LIEN CERTIFICATE
FOR PURPOSES OF FILING A JUDGMENT LIEN, THE FOLLOWING INFORMATION
IS SUBMITTED IN ACCORDANCE WITH s. 55.203, FLORIDA STATUTES.
1.
JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF AN INDIVIDUAL, IS:
___________________________________________ __________________________________ _______
LAST NAME
FIRST NAME
M. I.
________________________________________________________________________________________
MAILING ADDRESS
_____________________________________________________ _____________ __________________
CITY
ST
ZIP
2.
ADDITIONAL JUDGMENT DEBTOR, IF AN INDIVIDUAL, IS:
___________________________________________ __________________________________ _______
LAST NAME
FIRST NAME
M. I.
________________________________________________________________________________________
MAILING ADDRESS
_____________________________________________________ _____________ __________________
CITY
ST
ZIP
3.
JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF A BUSINESS ENTITY, IS:
________________________________________________________________________________________
BUSINESS ENTITY NAME
________________________________________________________________________________________
MAILING ADDRESS
_____________________________________________________
______________ ________________
CITY
ST
ZIP
4.
FEDERAL EMPLOYER IDENTIFICATION NUMBER: _____________________________________________________
5.
____________________________________________
DEPARTMENT OF STATE DOCUMENT FILE NUMBER:
PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE
6.
JUDGMENT CREDITOR (PLAINTIFF) NAME AS SHOWN ON JUDGMENT OR CURRENT OWNER OF JUDGMENT,
IF ASSIGNED:
______________________________________________________________________________________________________________________
CREDITOR NAME (S)
____________________________________________________________________________________________________
MAILING ADDRESS
______________________________________________________ _______________ _______________
CITY
ST
ZIP
THIS SPACE FOR USE BY FILING OFFICER
7.
____________________________________________
DEPARTMENT OF STATE DOCUMENT FILE NUMBER:
PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE
8.
OWNER’S ATTORNEY OR AUTHORIZED REPRESENTATIVE: (ACKNOWLEDGMENT OF FILING WILL BE SENT
11.
NAME OF COURT:
TO THIS ADDRESS)
____________________________________________________________
______________________________________________________________________________
NAME
____________________________________________________________
________________________________________________________________________________________
12.
CASE NUMBER: ______________________________________________
MAILING ADDRESS
13.
,
DATE OF ENTRY: ________________ ________
___________
______________________________________________________ ______________ ________________
MONTH
DAY
YEAR
CITY
ST
ZIP
9.
AMOUNT DUE ON MONEY JUDGMENT: _______________________________________________________________
10.
APPLICABLE STATUTORY INTEREST RATE: ___________________________________________________________
UNDER PENALTY OF PERJURY, I hereby certify that: (1) The judgment above described has become final and there is no stay of the judgment or its enforcement in effect; (2) All of the
information set forth above is true, correct, current and complete; (3) I have not previously filed a Judgment Lien Certificate regarding the above judgment with the Department of State; and,
(4) I have complied with all applicable laws in submitting this Judgment Lien Certificate for filing.
____________
__________________________________________________________________________
_______________________________________________________________________________
SIGNATURE OF CREDITOR OR AUTHORIZED REPRESENTATIVE
PRINT NAME
NON-REFUNDABLE PROCESSING FEE:
JUDGMENT LIEN WITH ONE DEBTOR $ 20.00
EACH ADDITIONAL DEBTOR $ 5.00
EACH ATTACHED PAGE, IF NECESSARY $ 5.00
(NO CHARGE FOR CREDITOR AFFIDAVIT)
CERTIFIED COPY REQUESTED $10.00
Division of Corporations • P.O. Box 6250 • Tallahassee, Fl 32314 • 850-245-6011
Make Checks Payable to: Florida Department of State
CR2E091 (04/08)
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