IN THE CIRCUIT COURT FOR FLORIDA IN RE: ESTATE OF COUNTY, PROBATE DIVISION File No. Deceased. Division PERSONAL REPRESENTATIVE'S PROOF OF CLAIM (Debts Paid) The undersigned, as personal representative of the above estate, has paid the following debts of the decedent: 1. Name of creditor: Address: Basis of claim: Security: Contingent Unliquidated Matured Unmatured [Check the above which apply] Amount: 2. Name of creditor: Address: Basis of claim: Security: Contingent Unliquidated Matured Amount: Unmatured [Check the above which apply] 3. Name of creditor: Address: Basis of claim: Security: Contingent Unliquidated Matured Amount: Unmatured [Check the above which apply] Bar Form No. P-3.1001 - 1 of 2 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com 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 __________________________, ________. Attorney for Personal Representative Email Addresses: Personal Representative Florida Bar No. (address) Telephone: I certify that a copy hereof has been furnished to by on , . Attorney for Personal Representative [Print or Type Names Under All Signature Lines] Bar Form No. P-3.1001 - 2 of 2 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com