(a) For Individuals.

(CAPTION)

FACT INFORMATION SHEET

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’s License Number: ___________________________________________

Marital Status: ____________ Spouse’s Name: ___________________________________________

********

Spouse Related Portion

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.)

Describe all other accounts or investments you may have, including stocks, mutual funds, savings bonds, or annuities, on the back of this sheet or on 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 # _______________________

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 #: ____________ 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, market value, 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:

a. Your last pay stub.

b. Your last 3 statements for each bank, savings, credit union, or other financial account.

c. Your motor vehicle registrations and titles.

d. Any deeds or titles to any real or personal property you own or are buying, or leases to property you are renting.

e. Your financial statements, loan applications, or lists of assets and liabilities submitted to any person or entity within the last 3 years.

f. 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 ….

Sworn to (or affirmed) and subscribed before me this ________ day of ______ (year) by

(name of person making statement)

___________________________

Notary Public of Florida

My Commission expires:

………………

Personally known ________ OR Produced Identification _______

Type of identification produced ___________________________

YOU MUST MAIL OR DELIVER THIS COMPLETED FORM, WITH ALL ATTACHMENTS, TO THE JUDGMENT CREDITOR OR THE JUDGMENT CREDITOR’S ATTORNEY, BUT DO NOT FILE THIS FORM WITH THE CLERK OF COURT.

(b) For Corporations and Other Business Entities.

(CAPTION)

FACT INFORMATION SHEET

Name of entity: _______________________________________________

Name and title of person filling out this form: _______________________________________________

Telephone number: _______________________________________________

Place of business: _______________________________________________

Mailing address (if different): _______________________________________________

Gross/taxable income reported for federal income tax purposes last three years:

$_____________ /$_____________$_____________/$_____________$_____________/$

Taxpayer identification number: _____________

Is this entity an S corporation for federal income tax purposes? _________ Yes __________ No

Average number of employees per month ____________________________

Name of each shareholder, member, or partner owning 5% or more of the entity’s common stock, preferred stock, or other equity interest:

__________________________________________________________

__________________________________________________________

__________________________________________________________

Names of officers, directors, members, or partners: _______________________________________

Checking account at: ____________________ Account # ______________________

Savings account at: ___________________________ Account # ___________________

Does the entity own any vehicles? ___________ Yes ___________ No

For each vehicle please state: _______________________________________

Year/Make/Model: _______________ Color: ______________________

Vehicle ID No: __________________ Tag No: ___________ Mileage: _______________

Names on Title:_________________ Present Value: $ _________________

Loan Owed to: _______________________________________

Balance on Loan: $ _______________________________________

Monthly Payment: $ _______________________________________

Does the entity own any real property? _____________ Yes _______________ No

If yes, please state the address(es): _______________________________________

Please check if the entity owns the following

_______ Boat

_______ Camper

_______ Stocks/bonds

_______ Other real property

_______ Other personal property

Please attach copies of the following:

1. Copies of state and federal income tax returns for the past 3 years.

2. All bank, savings and loan, and other account books and statements for accounts in institutions in which the entity had any legal or equitable interest for the past 3 years.

3. All canceled checks for the 12 months immediately preceding the service date of this Fact Information Sheet for accounts in which the entity 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 this lawsuit was filed.

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 entity within the 12 months immediately preceding the date this lawsuit was filed.

6. Motor vehicle or vessel documents, including titles and registrations relating to any motor vehicles or vessels owned by the entity alone or with others.

7. Financial statements as to the entity’s assets, liabilities, and owner’s equity prepared within the 12 months immediately preceding the service date of this Fact Information Sheet.

8. Minutes of all meetings of the entity’s members, partners, shareholders, or board of directors held within 2 years of the service date of this Fact Information Sheet.

9. Resolutions of the entity’s members, partners, shareholders, or board of directors passed within 2 years of the service date of this Fact Information Sheet.

UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE FOREGOING ANSWERS ARE TRUE AND COMPLETE.

__________________________________

Judgment Debtor’s Designated

Representative/Title

STATE OF FLORIDA

COUNTY OF ….

Sworn to (or affirmed) and subscribed before me this _____ day of ____________ (year) by (name of person making statement).

Personally known ____ OR Produced identification __________

Type of identification produced __________________________

YOU MUST MAIL OR DELIVER THIS COMPLETED FORM, WITH ALL ATTACHMENTS, TO THE PLAINTIFF’S JUDGMENT CREDITOR OR THE PLAINTIFF’S JUDGMENT CREDITOR’S ATTORNEY, BUT DO NOT FILE THIS FORM WITH THE CLERK OF THE COURT.