IN THE SEVENTEENTH JUDICIAL CIRCUIT, IN AND FOR BROWARD COUNTY, FLORIDA PROBATE In Re: Estate of Case No.: Judge: AFFIDAVIT CONCERNING CRIMINAL HISTORY This affidavit must be filed by all Personal Representatives and Petitioners in all testate and intestate cases, formal and summary administrations. I,, swear or affirm: I certify that I have not been convicted of a felony. (initial) I certify that I have been convicted of a felony. List offense, date of conviction, (initial) court and case number, state and county of the court, regardless of whether adjudication was entered or withheld. Offense(s) Date(s) of conviction Court & case number State & County of the court Under penalties of perjury, I declare that I have read the foregoing Affidavit Concerning Criminal History and the facts stated herein are true. Affiant222s signature Print name and address of Affiant State of County of Subscribed and sworn before me this day of , 20. Notary Public or Deputy Clerk Personally known Produced identificationPrint, type or stamp commissioned name of Notary Public or Deputy Clerk Type of identification: American LegalNet, Inc. www.FormsWorkFlow.com