IN THE SMALL CLIAMS COURT IN THE

SEVENTEENTH JUDICIAL CIRCUIT IN AND

FOR BROWARD COUNTY, FLORIDA

                                                CASE NO.:

a Florida resident,

                        Plaintiff

v.

                        Defendant

_____________________________/

II. TYPE OF CASE (Place an x in one box only. If the case fits more than one type of case, select the most definitive.)

Simplified Dissolution                    Professional Malpractice                Contracts

 Dissolution                                      Products Liability                            Condominium

 Support – IV-D                                 Auto Negligence                             Real property/Mortgage

 URESA – IV-D                                 Other Negligence                            Foreclosure

 URESA – Non IV-D                                                                                         Eminent Domain

 Domestic Violence                                                                                          Other

 Other Domestic Relations

III. Is Jury Trial Demanded In Complaint?

 Yes

 No

DATE:                                                            Attorney for Plaintiff 

                                                                        335 S. Biscayne Blvd., #UPH00

                                                                        Miami, Florida 33131

                                                                        p:  305-394-8546

                                                                                                f:   866-380-8986

                                                                        Michael D. Stewart, Esq.