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IN THE CIRCUIT COURT, IN
THE TWENTIETH JUDICIAL CIRCUIT
IN AND FOR COLLIER COUNTY, FLORIDA
CIVIL DIVISION
CASE NO: 112020CA0003010001XX
NAPLES HMA LLC DBA PHYSICIANS REGIONAL MEDICAL CENTER- PINE RIDGE
Plaintiff(s),
-vs-
RICHARD SMITH
Defendant(s).
FINAL JUDGMENT
THIS CAUSE having come before this Court upon Plaintiff's Motion for Final Judgment Based
on Default in Stipulation filed herein, and this Court having considered the evidence and being fully
advised in the premises, finding it has jurisdiction of the subject matter and over the parties, it is:
ADJUDGED that the Plaintiff, Naples Hma Llc Dba Physicians Regional Medical Center- Pine
Ridge, recovers from Defendant, Richard Smith whose address is 1148 Oxford Ln, Naples, FL 34105
the principal sum of $101,242.09, interest in the sum of $0.00, and Court Costs in the sum of $484.35,
less payments made in the amount of $2,449.00, making a total sum of $99,277.44, all of which shall bear
interest at the applicable statutory rate, for all of which let execution issue. The Court reserves
jurisdiction to amend this Final Judgment to add other jointly and severally liable parties.
IT IS ADJUDGED FURTHER that, pursuant to FL.R.Civ.P.1.560(b), the Defendant shall
complete, under oath, Form 1.977 (Fact Information Sheet), including all required attachments, and serve
it on the Plaintiff's Attorney within 45 days of this Final Judgment. Jurisdiction of this case is retained to
enter further Orders that are proper to compel the Defendant to complete the Form 1.977.
The Fact Information Sheet shall not be copied for recording purposes.
DONE AND ORDERED in Chambers in Naples, Collier County, Florida this_7/_ day of
Ottobea Z___, 2020.
roe gp 0 Magee —
Cc ircuit Court Judge
Lotane & Associates, PA, 1980 Michigan Avenue, Cocoa, FL 32922
Richard Smith at 1148 Oxford Ln, Naples, FL 34105
| I tl | | i l
* @ 399 95
399952_79006067_CE
2 J *
FILEDIQ” 5 720 15B400H Lert
IN THE CIRCUIT COURT, IN
THE TWENTIETH JUDICIAL CIRCUIT
IN AND FOR COLLIER COUNTY, FLORIDA
CIVIL DIVISION
CASE NO: 112020CA0003010001XX
NAPLES HMA LLC DBA PHYSICIANS REGIONAL MEDICAL CENTER- PINE RIDGE
Plaintiff(s),
-vs-
RICHARD SMITH
Defendant(s).
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
per
—_ Commissions or bonuses are based on
Average Commissions or Bonuses: $
Other Personal Income: $ from
(Explain details on the back of this sheet or an additional sheet if necessary.)
Social Security Number: Birthdate:
Driver's License Number:
Marital Status: Spouse's Name:
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 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#
OA
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 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#: Tag No: Mileage:
Names on Title: Present Value: $
Loan Owed to:
Balance on Loan: $
Monthly Payments: $
(List all other automobiles, as well as other vehicles, such as boats, motorcycles, bicycles, or aircraft, on the back
of this sheet or 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, saving, credit union, or other financial account.
¢, 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 by means of physical presence or online
notarization this day of. »20___, by » Who is
personally known to me or has produced. as identification and who O) did 0
did not take an oath.
Notary Public
State of Florida
Commission expires:
JUDGMENT DEBTOR SHALL MAIL THE ORIGINAL COMPLETED FACT INFORMATION SHEET
TO THE JUDGMENT CREDITORS ATTORNEY. THE JUDGMENT DEBTOR SHALL NOT FILE THE
FACT INFORMATION SHEET WITH THE COURT.
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IN THE CIRCUIT COURT, IN THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR COLLIER COUNTY, FLORIDA CIVIL DIVISION CASE NO: 112020CA0003010001XX NAPLES HMA LLC DBA PHYSICIANS REGIONAL MEDICAL CENTER- PINE RIDGE Plaintiff(s), -vs- RICHARD SMITH Defendant(s). FINAL JUDGMENT THIS CAUSE having come before this Court upon Plaintiff's Motion for Final Judgment Based on Default in Stipulation filed herein, and this Court having considered the evidence and being fully advised in the premises, finding it has jurisdiction of the subject matter and over the parties, it is: ADJUDGED that the Plaintiff, Naples Hma Llc Dba Physicians Regional Medical Center- Pine Ridge, recovers from Defendant, Richard Smith whose address is 1148 Oxford Ln, Naples, FL 34105 the principal sum of $101,242.09, interest in the sum of $0.00, and Court Costs in the sum of $484.35, less payments made in the amount of $2,449.00, making a total sum of $99,277.44, all of which shall bear interest at the applicable statutory rate, for all of which let execution issue. The Court reserves jurisdiction to amend this Final Judgment to add other jointly and severally liable parties. IT IS ADJUDGED FURTHER that, pursuant to FL.R.Civ.P.1.560(b), the Defendant shall complete, under oath, Form 1.977 (Fact Information Sheet), including all required attachments, and serve it on the Plaintiff's Attorney within 45 days of this Final Judgment. Jurisdiction of this case is retained to enter further Orders that are proper to compel the Defendant to complete the Form 1.977. The Fact Information Sheet shall not be copied for recording purposes. DONE AND ORDERED in Chambers in Naples, Collier County, Florida this_7/_ day of Ottobea Z___, 2020. roe gp 0 Magee — Cc ircuit Court Judge Lotane & Associates, PA, 1980 Michigan Avenue, Cocoa, FL 32922 Richard Smith at 1148 Oxford Ln, Naples, FL 34105 | I tl | | i l * @ 399 95 399952_79006067_CE 2 J * FILEDIQ” 5 720 15B400H Lert IN THE CIRCUIT COURT, IN THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR COLLIER COUNTY, FLORIDA CIVIL DIVISION CASE NO: 112020CA0003010001XX NAPLES HMA LLC DBA PHYSICIANS REGIONAL MEDICAL CENTER- PINE RIDGE Plaintiff(s), -vs- RICHARD SMITH Defendant(s). 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 per —_ Commissions or bonuses are based on Average Commissions or Bonuses: $ Other Personal Income: $ from (Explain details on the back of this sheet or an additional sheet if necessary.) Social Security Number: Birthdate: Driver's License Number: Marital Status: Spouse's Name: 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 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# OA 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 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#: Tag No: Mileage: Names on Title: Present Value: $ Loan Owed to: Balance on Loan: $ Monthly Payments: $ (List all other automobiles, as well as other vehicles, such as boats, motorcycles, bicycles, or aircraft, on the back of this sheet or 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, saving, credit union, or other financial account. ¢, 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 by means of physical presence or online notarization this day of. »20___, by » Who is personally known to me or has produced. as identification and who O) did 0 did not take an oath. Notary Public State of Florida Commission expires: JUDGMENT DEBTOR SHALL MAIL THE ORIGINAL COMPLETED FACT INFORMATION SHEET TO THE JUDGMENT CREDITORS ATTORNEY. THE JUDGMENT DEBTOR SHALL NOT FILE THE FACT INFORMATION SHEET WITH THE COURT.