Fla. Sm. Clm. R. Form 7.343
(a) For Individuals
(CAPTION)
FACT INFORMATION SHEET - INDIVIDUAL
Full Legal Name:__________________________
Nicknames or Aliases:__________________________
Residence Address:__________________________
Mailing Address (if different):__________________________
Telephone Numbers: (Home)__________________________
(Business)__________________________
Name of Employer:__________________________
Address of Employer:__________________________
Position or Job Description:__________________________
Rate of Pay: $ ____ per _____ Average Paycheck: $ ____ per ____
Average Commissions or Bonuses: $ ___ per ____Commissions 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 License Number:_____________ Issuing State:______
Marital Status:______ Spouse's Name:_______________
Spouse's Address (if different):____________________________
Spouse's Social Security Number:___________ Birthdate:__________
Spouse's Employer:_____________
Spouse's Average Paycheck or Income: $_____ per___________
Other Family Income: $ _____ per _______ (Explain details on back of this sheet or an additional sheet if necessary.)
Names and Ages of All Your Children (and addresses if not living with you):__
___________________________________________________________
Child Support or Alimony Paid: $______ per_______
Names of Others You Live With:_________________
Who is Head of Your Household?_____ You _____ Spouse______
Other Person
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 this sheet or an additional 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 an additional 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 # (VIN):__________ Tag No:______ Mileage:_____
Names on Title:_________________________
Present Value: $ ________________________
Loan Owed to:__________________________
Balance on Loan: $_______________________
Monthly Payment: $____________ (List all other automobiles, as well as other vehicles, such as boats, motorcycles, bicycles, or aircraft, on the back of this sheet or an additional sheet if necessary.)
Have you given, sold, loaned, or transferred any real or personal property worth more than $100 to any person in the last year? If your answer is "yes," describe the property and sale price, and give the name and address of the person who received the property.
Does anyone owe you money? Amount Owed: $______________
Name and Address of Person Owing Money:_________________
Reason money is owed:_________________________________
Please attach copies of the following:
1. Your last pay stub.
2. Your last 3 statements for each bank, savings, credit union, or other financial account.
3. Your motor vehicle registrations and titles.
4. Any deeds or titles to any real or personal property you own or are buying, or leases to property you are renting.
5. Your last 2 income tax returns filed.
UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE TRUE AND COMPLETE.
_____________
Judgment Debtor
STATE OF FLORIDA
COUNTY OF ....................
The foregoing instrument was acknowledged before me on .....(date)....., by ...................., who is personally known to me or has produced .................... as identification and who .....did/did not.....take an oath.
WITNESS my hand and official seal, on .....(date)......
______________________
Notary Public State of Florida
My Commission expires: ....................
SERVE THE COMPLETED FORM AND ATTACH ANY COPIES, PURSUANT TO FLORIDA RULE OF GENERAL PRACTICE AND JUDICIAL ADMINNISTRATION 2.516, TO THE JUDGMENT CREDITOR OR THE JUDGMENT CREDITOR'S ATTORNEY. DO NOT FILE THIS FORM WITH THE COURT.
(b) For Corporate Entities
(CAPTION)
FACT INFORMATION SHEET - BUSINESS ENTITY
Name/Title of person filling out this form:____________________
Address:____________________________________________
Telephone Number: Home:_____ Business:_____________
Address of Business Entity: _________________________
Type of Entity: (Check One) [] Corporation [] Partnership [] Limited Partnership [] Sole Proprietorship [] Limited Liability Company (LLC) [] Professional Association (PA) [] Other: (Please Explain)
Does Business Entity own/have interest in any other business entity? If so please explain.
Gross/Taxable income reported for Federal Income Tax purposes last three years:
$ _____________
$ _____________
$ _____________
Taxpayer Identification Number: ____________________________
List Partners (General or Limited and Designate Percentage of Ownership):______________
Average No. of Employees/Month:_______________
Names of Officers and Directors:________________
Checking Account at:________ Account No:_________
Savings Account At:________ Account No:_________
Does the Business Entity own any vehicles:________________________
Years/Makes/Models:_________________________________________
Vehicle ID # (VIN):___________________________________________
Tag Nos.:__________________________________________________
Loans Outstanding:___________________________________________
Does the Business Entity own any real property: YES _____ NO ______
If Yes: Address: _____________________________________________
Please check if the business entity owns the following:
_____Boat _____Mobile Home/RV
_____Stocks/Bonds _____Other Real Property
_____Other Personal Property _____Intangible Property
Please attach copies of the following:
1. All tax returns for the past 3 years, including but not limited to state and federal income tax returns and tangible personal property tax returns.
2. All bank, savings and loan, and other account books or statements for accounts in institutions in which the defendant had any legal or equitable interest for the past 3 years.
3. All canceled checks for the 12 months immediately preceding the date of this judgment for accounts in which the defendant held any legal or equitable interest.
4. All deeds, leases, mortgages, or other written instruments evidencing any interest in or ownership of real property at any time within the 12 months immediately preceding the date of this judgment.
5. Bills of sale or other written evidence of the gift, sale, purchase, or other transfer of any personal or real property to or from the defendant within the 12 months immediately preceding the date of filing this lawsuit. Any transfer of property within the last year other than ordinary course of business transactions.
6. Motor vehicle documents, including titles and registrations relating to any motor vehicles owned by the defendant alone or with others.
7. Financial statements and any other business records, including but not limited to accounts payable and accounts receivable ledgers, as to the defendant's assets and liabilities prepared within the 12 months immediately preceding the date of this judgment.
8. Copies of articles, by-laws, partnership agreement, operating agreement, and any other governing documents, and minutes of all meetings of the defendant's shareholders, board of directors, or members held within 2 years of the date of this judgment.
9. Resolutions of the shareholders, board of directors, or members passed within 2 years of the date of this judgment.
10. A list or schedule of all inventory and equipment.
UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE TRUE AND COMPLETE.
___________________
Defendant's Designated
Representative
Title:____________
STATE OF FLORIDA COUNTY OF
The foregoing instrument was acknowledged before me on .....(date)....., by _________, as the defendant's duly authorized representative, who is personally known to me or has produced as identification and who __ did/did not ___ take an oath.
WITNESS my hand and official seal, on .....(date)......
______________________
Notary Public State of Florida
My Commission expires:_______________
SERVE THE COMPLETED FORM AND ATTACH ANY COPIES, PURSUANT TO FLORIDA RULE OF GENERAL PRACTICE AND JUDICIAL ADMINISTRATION 2.516, TO THE JUDGMENT CREDITOR OR THE JUDGMENT CREDITOR'S ATTORNEY. DO NOT FILE THIS FORM WITH THE COURT.
FL. Sm. Clm. R. Form 7.343