Washington County Clerk of Court – Lora C. Bell Clerk of ...



IN THE COUNTY COURTWASHINGTON COUNTY, FLORIDACASE NUMBER:DIVISION: Small Claims__________________________________(Plaintiff)VS.___________________________________(Defendant)FACT INFORMATION SHEET, INDIVIDUALFull Legal Name: ____________________________________________________________________________________Nickname or Aliases:_______________________________________________________________________________Residence Address:______________________________________________________________________________Mailing Address (if different): __________________________________________________________________________Telephone number: ____________________________Business number:_______________________________________Name of Employer: __________________________________________________________________________________Address of Employer:_____________________________________________________________________________Position or Job Description: ___________________________________________________________________________Rate of Pay: ___________________________________ Per:_________________________________________________Average Paycheck:__________________________________ Per:_____________________________________________Average Commission or Bonuses: ______________________________________________________________________Commission or Bonuses are based on: ___________________________________________________________________Other Personal Income:________________________________From:________________________________________(Explain details on the back of this sheet or an additional sheet if necessary)Social Security Number:__________________________________Birthdate:___________________________________Driver’s License Number:_____________________________________________________________________________Marital Status:________________________________ Spouse’s Name:_________________________________________Spouse’s Address (if different):_________________________________________________________________________Spouses Social Security Number:____________________________ Birthdate:___________________________________Spouse’s Employer:_____________________________________________________________________________Spouse’s Average Paycheck or Income: $______________________ per _______________________________________Other Family Income $___________________________ per_________________________________________________(Explain details on the back of this sheet or an additional sheet if necessary.)Names and Ages of all of your children (and addresses if not living with you): _____________________________________________________________________________________________________________________________________________________________________________________________________________Child Support or Alimony Paid $ ___________________ Per__________________________________________________Names of Others you LiveWith:_________________________________________________________________________Who is Head of Your Household? You:_________ Spouse________ Other:______________________________________Checking Account at:_________________________ Account #:_______________________________________________Savings Account at:____________________________ Account #:_____________________________________________(Describe all other accounts or investments you may have, including stocks, mutual funds, savings bonds, or annuities,on the back of the sheet or an addition sheet if necessary)For Real Estate (land) You Own or are Buying: ____________________________________________________________Address: _____________________________________________________________________________________All Names on Title: _____________________________________________________________________Mortgage Owed to: __________________________________________________________________________________Balance Owed: _______________________________ Monthly Payment $______________________________________(Attach a copy of the deed or mortgage, or list the legal description of the property on the back of this sheet or anadditional sheet if necessary. Also provide the same information on any other property you own or are buying. )For all motor Vehicles You Own or are Buying: ____________________________________________________________Year: ______________ Make:____________ Model:_____________________ Color:_____________________________Vehicle ID #:______________________ Tag #_________________________ Mileage:_____________________________Names on Title: _____________________________________________________________________________________Loan Owed to: _____________________________________________________________________________________Balance on Loan: ___________Present Value_______________ Monthly Payments: ____________________________(List all other automobiles, as well as other vehicles, such as boats, motorcycles, bicycles, or aircraft, on the back of thissheet or any additional sheet if necessary.)Have you given, sold, loaned, or transferred any real or personal property worth more than $100.00 to any person in thelast year? Yes: ______ No:________ if you answer “yes” describe the property and sale price, and five the name andaddress of the person who received the property: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does anyone owe you money? Yes:__________ No:__________ Amount Owed:$________________________________Name and Address of person owing Money:______________________________________________________________Reason Money is Owed:______________________________________________________________________________Please attach copies of the following:Your last pay stub.Your last 3 statements for each bank, savings, credit union or other financial account.Your motor vehicle registrations and titles.Any deeds or titles to any real or personal property you own or are buying, leases to property you are renting.UNDER PENALTY OF PURGERY, I SWEAR OR AFFIRM THATTHE FOREGOING ANSWERS ARE TRUE AND COMPLETE.The foregoing instrument was acknowledged before me on ______________ by ___________________ who ispersonally known to me or has produced as identification and who _____________did ________ did not take an oath.WITNESS my hand and official seal on __________________________________________________________________ (Signature of Notary Public) ................
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