IN THE COUNTY COURT OF POLK COUNTY, FLORIDA

CIVIL DIVISION

CASE NO. ____________________________

Plaintiff,

vs.

Defendant.

_________________________________________________/ 

STATE OF FLORIDA

COUNTY OF POLK

    BEFORE ME, the undersigned authority, personally appeared ________________________________________, the above named plaintiff, who, after being duly sworn, deposes and says:

    1. On __________________________________, the plaintiff was awarded a judgment against the defendant in execution, _____________________________________________________________________________, in the sum of $____________ plus court costs of $____________ and interest; and

    2. A Writ of Execution has been placed in the hands of the Sheriff of ________________ County, the county in which the defendant in execution resides and the Writ of Execution is valid and outstanding and remains unsatisfied; and

    3. In accordance with the provisions of Florida Statute 56.29, the plaintiff requests proceedings supplementary to execution.

_________________________________________

Plaintiff

SWORN TO and subscribed before me this _____ day of _____________________, 19____.

                                                                                                                        RICHARD M. WEISS, CLERK

                                                                                                                        Circuit and County Court

(SEAL)                                                                                                              By______________________________________

                                                                                                                            Deputy Clerk/Notary Public

           Type of identification presented:______________________________