IN THE COUNTY COURT OF POLK COUNTY, FLORIDA

CIVIL DIVISION

CASE NO. _________________

Plaintiff,

vs.

Defendant.

__________________________________/

The above named Plaintiff sues the above named defendant and alleges:

2.     On _________________________, plaintiff and defendant entered into a written contract, a copy of which is attached, marked           Exhibit A.

3.     Defendant failed to make the payment due on said contract on _______________________ at which time there was still a           balance of $_______________ due to plaintiff.

4.     Plaintiff subsequently took possession of the following described property pursuant to the security interest retained by the           terms of the said contract:

5.     On _________________________, the above described property was sold at public/private sale after written notice was duly           made upon defendant. A copy of said notice is attached, marked Exhibit B.

6.     The proceeds of said sale in the amount of $_______________ were applied to the balance owed to plaintiff by defendant, and           after appropriate adjustment for prepaid interest and/or insurance and costs of repossession and sale of the property which are          itemized and attached as Exhibit C, defendant owed a remaining balance of $_______________ to plaintiff.

7.     Plaintiff notified defendant of the remaining balance on _________________________.

8.     Plaintiff says that the foregoing is a just and true statement of the amount owing by the above named defendant, and that the           action has been brought in the County in which venue is proper, pursuant to Chapter 47, Florida Statutes.

                                                                                                                        ________________________________________
                                                                                                                        Plaintiff

                                                                                                                        ____________________
                                                                                                                        Phone

Subscribed and sworn to before me this _____ day of
Personally Known

__________________, 19____

RICHARD M. WEISS, Clerk                                                  ____     Produced Identification

BY___________________________D.C.                                ____     Type of identification presented: ________________________

OR

BY___________________________

21.doc (08/97)