IN THE CIRCUIT COURT FOR FLORIDA IN RE: ESTATE OF COUNTY, PROBATE DIVISION File No. Division Deceased. STATEMENT OF CLAIM BY The undersigned hereby presents for filing against the above estate this statement of claim and alleges: 1. 2. The basis for the claim is . The name and address of the claimant are and the name and address of the claimant's attorney, if any, are as set forth below. 3. 4. uncertainty is . 5. The claim is not secured. If secured, the security consists of . 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 __________________________, ________. The amount of the claim is $ , which . amount is now due, or, if not due, will become due on is not not) The claim (is) (is contingent or unliquidated. If contingent or unliquidated, the nature Attorney for Claimant Email Addresses: Claimant Copy mailed to attorney for Personal Representative on ____________________________, _______. CLERK OF THE CIRCUIT COURT __________________________________ ______________________________________ Florida Bar No. (address) Telephone: By: ________________________________ [Print or Type Names Under All Signature Lines] Bar Form No. P-3.1010 © Florida Lawyers Support Services, Inc. Revised January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com