Fla. R. Civ. P. Form 1.977
(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.
FL. R. Civ. P. Form 1.977
Committee Notes
2000 Adoption. This form is added to comply with amendments to rule 1.560.
2013 Amendment. This amendment clarifies that the judgment debtor should mail or deliver the Fact Information Sheet only to the judgment creditor or the judgment creditor's attorney, and should not file the Fact Information Sheet with the clerk of the court.