SECOND JUDGMENT LIEN CERTIFICATE
FOR PURPOSES OF FILING A SECOND JUDGMENT LIEN, THE FOLLOWING INFORMATION IS SUBMITTED IN ACCORDANCE WITH s. 55.204, FLORIDA STATUTES. THIS SECOND JUDGMENT LIEN IS A NEW LIEN AND NOT A CONTINUATION OF THE ORIGINAL LIEN. 1. __________________________________________________________________________________________
FILE NUMBER ASSIGNED TO THE RECORD OF THE ORIGINAL JUDGMENT LIEN CERTIFICATE:
DO NOT PHOTOCOPY THIS FORM PRIOR TO USE.
BAR CODE MUST BE LEGIBLE.
2. DATE FILED WITH DEPARTMENT OF STATE: ___________________________ ____________________ ,
MONTH DAY
____________ YEAR
3. JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF AN INDIVIDUAL, IS:
______________________________________________________________________ LAST NAME _____________________________________ FIRST NAME _________ M. I.
________________________________________________________________________________________________________________________ MAILING ADDRESS _______________________________________________________________________________________ CITY __________ ST ___________________ ZIP
4. ADDITIONAL JUDGMENT DEBTOR, IF AN INDIVIDUAL, IS:
_______________________________________________________________________ LAST NAME _____________________________________ FIRST NAME ________ M.I.
________________________________________________________________________________________________________________________ MAILING ADDRESS ______________________________________________________________________________________ CITY __________ ST ____________________ ZIP
5. JUDGMENT DEBTOR (DEFENDANT) NAME AS SHOWN ON JUDGMENT, IF A BUSINESS ENTITY, IS:
________________________________________________________________________________________________________________________ BUSINESS ENTITY NAME ________________________________________________________________________________________________________________________ MAILING ADDRESS ______________________________________________________________________________________ CITY __________ ST ____________________ ZIP
6. FEDERAL EMPLOYER IDENTIFICATION NUMBER: _________________________________________________________________ 7. DEPARTMENT OF STATE DOCUMENT FILE NUMBER: ______________________________________________________________
PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE
8. JUDGMENT CREDITOR (PLAINTIFF) NAME AS SHOWN ON JUDGMENT OR CURRENT OWNER OF JUDGMENT, IF ASSIGNED: __________________________________________________________________________________________
CREDITOR NAME (S)
THIS SPACE FOR USE BY FILING OFFICER
__________________________________________________________________________________________
MAILING ADDRESS
11. AMOUNT REMAINING UNPAID: $________________________________
_______________________________________________________________ ________ _______________ 9.
ST ZIP DEPARTMENT OF STATE DOCUMENT FILE NUMBER: ______________________________________________________________ PLEASE CHECK BOX IF DOCUMENT NUMBER IS NOT APPLICABLE CITY
APPLICABLE INTEREST RATE: __________________________________
INTEREST ACCRUED AMOUNT: $________________________________ 12. NAME OF COURT: ________________________________________________________________
10. OWNER'S ATTORNEY OR AUTHORIZED REPRESENTATIVE: (ACKNOWLEDGMENT OF THIS FILING WILL BE
SENT TO THIS ADDRESS)
________________________________________________________________
_________________________________________________________________________________________
NAME 13. CASE NUMBER: _______________________________________________
_________________________________________________________________________________________
MAILING ADDRESS 14. DATE OF ENTRY: _______________ ____________, _____________ MONTH DAY YEAR ST ZIP
______________________________________________________________ _________ ______________
CITY
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; and, (3) 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
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
CR2E092 (3/08)