IN THE COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA STATEMENT OF CLAIM DIVISION: CIVIL CASE NUMBER 05 - XXXX-XX IN RE: ESTATE OF CLOCK IN DECEASED The undersigned hereby presents for filing against the above estate this statement of claim and alleges: 1. The basis for the claim is 2. The social security or tax identification number of the claimant is and 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. The amount of the claim is $_______________ which amount is now due, or, if not due, will become due on _________________________, 20_____. 4. The claim uncertainty is is is not contingent or unliquidated. If contingent or unliquidated, the nature of the 5. The claim is 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. Executed this __________ day of ____________________, 20_____. Claimant Attorney for Claimant Address City Telephone No. State Zip Code Florida Bar No. Copy mailed to attorney for the Personal Representative on _________________________, 20___. BREVARD COUNTY CLERK OF COURTS BY DC DATE MUST BE FILED IN DUPLICATE. SEE NEXT PAGE FOR IMPORTANT INFORMATION LAW 218 Rev. 11-26-2012 BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS 1. Inapplicable words or statements may be stricken, but all information indicated in the form must be given. The nature and extent of the claim should be state in the spaces provided in sufficient detail to advise the personal representative of the estate to full particulars in order that the validity of the claim may be determined. 2. An exact copy of this claim must be filed with the Clerk of the Court at the time of filing. WARNING TO CLAIMANTS: The personal representative of the estate or any party interested in the estate has the right to object to any claim. If objection is filed, suit in a court of competent jurisdiction must be filed within the time allowed by law, or this claim will be barred. See Chapter 733.702, Chapter 733.703, and Chapter 733.705, Florida Statutes, and Rules 5.240 and 5.490 of the Florida Rules of Probate and Guardianship Procedure. American LegalNet, Inc. www.FormsWorkFlow.com