Fla. R. Civ. P. 1.977. — FACT INFORMATION SHEET

(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 State 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.