JUDGMENT LIEN CERTIFICATE
FOR PURPOSES OF FILING A JUDGMENT LIEN, THE FOLLOWING INFORMATION IS SUBMITTED IN ACCORDANCE WITH s. 55.203, FLORIDA STATUTES. 1.
JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF AN INDIVIDUAL, IS:
DO NOT PHOTOCOPY THIS FORM PRIOR TO USE. BAR CODE MUST BE LEGIBLE.
___________________________________________ __________________________________ _______
LAST NAME FIRST NAME M. I.
________________________________________________________________________________________
MAILING ADDRESS
_____________________________________________________ _____________ __________________
CITY ST ZIP
2. ADDITIONAL JUDGMENT DEBTOR, IF AN INDIVIDUAL, IS: ___________________________________________ __________________________________ _______
LAST NAME FIRST NAME M. I.
________________________________________________________________________________________
MAILING ADDRESS
_____________________________________________________ _____________ __________________
CITY ST ZIP
3.
JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF A BUSINESS ENTITY, IS:
________________________________________________________________________________________
BUSINESS ENTITY NAME
________________________________________________________________________________________
MAILING ADDRESS
_____________________________________________________
CITY
______________ ________________
ST ZIP
4. 5.
FEDERAL EMPLOYER IDENTIFICATION NUMBER: _____________________________________________________ DEPARTMENT OF STATE DOCUMENT FILE NUMBER: ____________________________________________
PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE
6.
JUDGMENT CREDITOR (PLAINTIFF) NAME AS SHOWN ON JUDGMENT OR CURRENT OWNER OF JUDGMENT, IF ASSIGNED:
______________________________________________________________________________________________________________________ CREDITOR NAME (S)
____________________________________________________________________________________________________
MAILING ADDRESS
______________________________________________________ _______________ _______________
CITY ST ZIP
7.
DEPARTMENT OF STATE DOCUMENT FILE NUMBER: ____________________________________________
PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE
THIS SPACE FOR USE BY FILING OFFICER
8.
OWNER'S ATTORNEY OR AUTHORIZED REPRESENTATIVE: (ACKNOWLEDGMENT OF FILING WILL BE SENT TO THIS ADDRESS)
11. NAME OF COURT:
____________________________________________________________ ____________________________________________________________
______________________________________________________________________________
NAME
________________________________________________________________________________________
MAILING ADDRESS
12. CASE NUMBER: ______________________________________________ 13. DATE OF ENTRY: ________________
MONTH ________ , ___________ DAY YEAR
______________________________________________________ ______________ ________________
CITY ST ZIP
9.
AMOUNT DUE ON MONEY JUDGMENT: _______________________________________________________________
10. APPLICABLE STATUTORY INTEREST RATE: ___________________________________________________________
UNDER PENALTY OF PERJURY, I hereby certify that: (1) The judgment above described has become final and there is no stay of the judgment or its enforcement in effect; (2) All of the information set forth above is true, correct, current and complete; (3) I have not previously filed a Judgment Lien Certificate regarding the above judgment with the Department of State; and, (4) I have complied with all applicable laws in submitting this Judgment Lien Certificate for filing.
______________________________________________________________________________________ SIGNATURE OF CREDITOR OR AUTHORIZED REPRESENTATIVE _______________________________________________________________________________ PRINT NAME
NON-REFUNDABLE PROCESSING FEE: JUDGMENT LIEN WITH ONE DEBTOR $ 20.00 EACH ATTACHED PAGE, IF NECESSARY $ 5.00 EACH ADDITIONAL DEBTOR $ 5.00 (NO CHARGE FOR CREDITOR AFFIDAVIT)
CERTIFIED COPY REQUESTED $10.00 Division of Corporations · P.O. Box 6250 · Tallahassee, Fl 32314 · 850-245-6011 Make Checks Payable to: Florida Department of State
CR2E091 (04/08)