IN THE CIRCUIT COURT FOR FLORIDA IN RE: ESTATE OF COUNTY, PROBATE DIVISION File No. Division Deceased. STATEMENT REGARDING CREDITORS (Individual) The undersigned, personal representative of the estate of alleges: 1. occurring on 2. 3. A Notice to Creditors has been published as required by law, with the first publication , . Diligent search has been made to ascertain the name and address of each creditor of the The names and, if known, the addresses of all creditors and other persons ascertained to , as , deceased, decedent and of all other persons having claims or demands against the estate. have or who may have claims or demands against the estate and who have not filed a timely claim, or who have not had their claim included in a Personal Representative's Proof of Claim filed in this proceeding, are: a. None b. Set forth on a schedule attached hereto. [Strike out inapplicable statement] 4. A copy of the Notice to Creditors was promptly served on each of the persons listed on the attached schedule (if any), except as otherwise indicated on that schedule. 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: ________________________________________ ________________________________________ Florida Bar No. Personal Representative (address) Telephone: Bar Form No. P-3.0831 © Florida Lawyers Support Services, Inc. Revised January 1, 2017 [Print or Type Names Under All Signature Lines] American LegalNet, Inc. www.FormsWorkFlow.com