FORM 7.334. STATEMENT OF CLAIM (PROMISSORY NOTE)

(CAPTION)

STATEMENT OF CLAIM

Plaintiff, , sues defendant, , and alleges:

1. This is an action for damages that do not exceed the jurisdictional
amount pursuant to Florida Small Claims Rule 7.010(b).

2. On .....(date)....., defendant executed and delivered to plaintiff a
promissory note, a copy being attached, in County, Florida.

3. Defendant failed to pay

(a) said note when due; or
(b) the installment payment due on said note on .....(date).....,
and plaintiff (has/has not) elected to accelerate payment of the balance.

4. There is now due, owing, and unpaid from defendant to plaintiff $
on said note with interest since .....(date)......

WHEREFORE, plaintiff demands judgment for damages against
defendant.

Committee Notes

1972 Amendment. Attach copy of note to each copy of the
statement of claim. Use 3(a) or (b) and 5 as applicable.