Washington County



IN THE COUNTY COURTWASHINGTON COUNTY, FLORIDACASE NUMBER:DIVISION: Small Claims_________________________________(Plaintiff)Vs._________________________________(Defendant)FACT INFORMATION SHEET- BUSINESS ENTITYName: _________________________________________Title:________________________________________Address: _____________________________________________________________________________________Telephone number (home):____________________________ Business:________________________________________Address of Business Entity:_______________________________________________________________ Type of Entity: (Check one)?Corporation ?Partnership ? Limited Partnership ? Sole Proprietorship ?Limited Liability Corporation(LLC) ? Professional Association (PA) ?Other:___________________________________________________Does Business Entity own/have interest in any other business entity? Please explain___________________________________________________________________________________________________Gross/Taxable income reported for Federal Income Tax purposes (last 3 years):$___________________________$ _________________________ $__________________________________Taxpayer Identification Number: _______________________________________________________________List Partners (General or limited and designate percentage of ownership:_____________________________________________________________________________________________________________Average Number of Employees/ Month: _________________________________________________________Names of Officers and Directors:_____________________________________________________________________________________________________________________________________________Checking Account at:_____________________ Account number:_____________________________________Savings Account at:______________________ Account number:_____________________________________Does the Business Entity own any vehicles? ______________________________________________________Years/ Makes/Models:_________________________________________________________________Vehicle ID numbers:______________________________________________________________________Tag numbers:______________________________________________________________________Outstanding Loans:_________________________________________________________________________Does the Business Entity own any real property: YES_______________ NO____________________________Address:_____________________________________________________________________________________________________________________________________________________Please check if the business entity owns the following:________ Boats________Stocks/Bonds________ Camper________ Other Real Property________Intangible Property________ Other Personal PropertyUNDER PENTALY OF PURGERY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE TRUE ANDCOMPLETE.____________________________________Defendants Designated RepresentativeTitle: ________________________________STATE OF FLORIDACOUNTY OF WASHINGTONThe foregoing instrument was acknowledged before me on ________________________ by______________________________________, who is personally known to me or has produced____________________________________ as identification and who ___________ did/did notTake an oath.WITNESS my hand and official seal on _______________________________._____________________________________Signature ................
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