§ Form 1.977 Fact Information Sheet
Form 1.977. Fact Information Sheet
(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 on 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 on 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 on 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 No: ____________ 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 on 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 ..........
The foregoing instrument was acknowledged before me this ..... day of .........., (year ..... ), by ..............., who is personally known to me or has produced ............... as identification and who ..... did/did not ..... take an oath.
WITNESS my hand and official seal, this ..... day of .........., (year ..... ).
________________________________________________________________________________
Notary Public
State of Florida
My Commission expires: ..........
THE JUDGMENT DEBTOR SHALL FILE WITH THE CLERK OF THE COURT A NOTICE OF COMPLIANCE AFTER THE ORIGINAL FACT INFORMATION SHEET, TOGETHER WITH ALL ATTACHMENTS, HAS BEEN DELIVERED TO THE JUDGMENT CREDITOR'S ATTORNEY, OR TO THE JUDGMENT CREDITOR IF THE JUDGMENT CREDITOR IS NOT REPRESENTED BY AN ATTORNEY.
(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 ..........
The foregoing instrument was acknowledged before me on ..... (date) ....., by ..............., who is personally known to me or has produced ............... as identification and who ..... did/did not ..... take an oath.
WITNESS my hand and official seal, this ..... day of ..............., ..... (year) .....
________________________________________________________________________________
Notary Public
State of Florida
My Commission expires: ..........
THE JUDGMENT DEBTOR SHALL FILE WITH THE CLERK OF THE COURT A NOTICE OF COMPLIANCE AFTER THE
ORIGINAL FACT INFORMATION SHEET, TOGETHER WITH ALL ATTACHMENTS, HAS BEEN DELIVERED TO THE
JUDGMENT CREDITOR'S ATTORNEY, OR TO THE JUDGMENT CREDITOR IF THE JUDGMENT CREDITOR IS NOT
REPRESENTED BY AN ATTORNEY.