IN THE CIRCUIT COURT FOR FLORIDA IN RE: GUARDIANSHIP OF COUNTY, PROBATE DIVISION File No. Division CLAIM OF STATE FOR FEES PAID AND PETITION FOR PAYMENT This claim for fees paid is filed on behalf of the state of Florida. A Petition to Determine Incapacity of , (the Ward) was filed in these proceedings, requiring the services of a court-appointed attorney and an examining committee. Compensation awarded the attorney and examining committee was paid by claimant as follows: $ $ to the examining committee to the court-appointed attorney The state has a creditor's claim against the guardianship assets, if filed within ninety (90) days after the entry of an order awarding attorney ad litem fees, and hereby files such claim and petitions the Court for an order authorizing immediate payment out of the property of the Ward. Signed on this day of , . State of Florida By: Copy mailed to attorney for the guardian on , . CLERK OF THE CIRCUIT COURT By: Bar Form No. G-2.080 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com