IN THE COUNTY COURT, IN AND FOR PINELLAS COUNTY, FLORIDA SMALL CLAIMS COURT
UCN: ______________________________ Reference No.: ______________________________
_____________________________________ _____________________________________
Plaintiff(s)
vs. _____________________________________ _____________________________________
Defendant(s)
SWORN STATEMENT OF COURT COSTS AND/OR INTEREST
I have incurred the following costs and/or am entitled to the following amount of interest in this matter: Court Costs: Filing Fee __________________________ Service of Process Fee _________________________________ Interest: Amount ____________________ Calculated Since ____________________________________ Rate ___________________________ Basis ____________________________________________________________________________________________ __________________________________________________________________________________________________ Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true. _______________________________________ Signature of Plaintiff _______________________________________ Date of Signature
SC 121 (Rev. 1/1/03)
SC 121 12/02