IN THE CIRCUIT COURT FOR FLORIDA IN RE: ESTATE OF COUNTY, PROBATE DIVISION File No. Division Deceased. PETITION FOR DISCHARGE (Single Personal Representative) Petitioner, personal representative of the above estate, alleges: 1. The decedent, , died on Letters of Administration were issued to petitioner on 2. , , . , a resident of , and , as Petitioner files herewith either a Final Accounting containing a complete report of all cash and property transactions and of all receipts and disbursements since the commencement of administration of this estate, or since the date of the last accounting filed herein, if any, or waivers signed by all interested persons, other than petitioner, waiving the filing of a Final Accounting. 3. Petitioner has fully administered this estate by making payment, settlement, or other disposition of all claims and debts that were presented, and by paying or making provision for the payment of all taxes and expenses of administration. 4. Petitioner has filed all required estate tax returns with the Internal Revenue Service and has obtained and filed with this court evidence of the satisfaction of this estate's obligations for federal estate taxes, if any. 5. The amount of compensation paid or to be paid to the personal representative, attorneys, accountants, appraisers, or other agents employed by the personal representative, and the manner of determining that compensation, is set forth in Exhibit A attached hereto. 6. Petitioner has made or proposes to make distribution of the assets of this estate as reflected in the plan of distribution set forth in the schedule attached hereto as Exhibit B. Bar Form No. P-5.0400 - 1 of 2 � Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com 7. The only persons, other than petitioner, having an interest in this proceeding and their respective addresses are: NAME ADDRESS 8. Any objections to the Petition for Discharge, the Final Accounting, the compensation paid or proposed to be paid, or the proposed distribution of assets, must be filed and served within 30 days from the date of service of the last of the Petition for Discharge or Final Accounting. Within 90 days after filing of the objection, a notice of hearing thereon must be served, or the objection is abandoned. 9. Objections, if any, shall be in writing and shall state with particularity the item or items to which the objection is directed and the grounds on which the objection is based. Petitioner requests that, after satisfactory proof has been presented that distribution has been made in accordance with the schedule of distribution and that claims of creditors have been paid or otherwise disposed of, an order be entered discharging petitioner as personal representative of this estate and releasing the surety on any bond which petitioner may have posted in this proceeding from any further liability on it. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Signed on this ________ day of _________________________, ________. Petitioner Attorney for Petitioner Email Addresses: Florida Bar No. (address) Telephone: Bar Form No. P-5.0400 - 2 of 2 � Florida Lawyers Support Services, Inc. January 1, 2017 [Print or Type Names Under All Signature Lines] American LegalNet, Inc. www.FormsWorkFlow.com