COVER SHEET

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                          Filing # 130069417 E-Filed 07/06/2021 10:09:18 AM

FORM 1.997, CIVIL COVER SHEET

The civil cover sheet and the information contained in it neither replace nor supplement the filing
and service of pleadings or other documents as required by law. This form must be filed by the
plaintiff or petitioner with the Clerk of Court for the purpose of reporting uniform data pursuant
to section 25.075, Florida Statutes. (See instructions for completion.)

I. CASE STYLE

IN THE CIRCUIT COURT OF THE FIFTH JUDICIAL CIRCUIT,
IN AND FOR CITRUS COUNTY, FLORIDA

Sandra Brown

Plaintiff Case # 2021 CA 000494 A
Judge
vs.
Citrus Memorial Hospital
Defendant

Il. AMOUNT OF CLAIM
Please indicate the estimated amount of the claim, rounded to the nearest dollar. The estimated amount of
the claim is requested for data collection and clerical processing purposes only. The amount of the claim
shall not be used for any other purpose.

$8,000 or less
$8,001 - $30,000
$30,001- $50,000
1 $50,001- $75,000
$75,001 - $1…