FIFTH JUDICIAL CIRCUIT IN AND FOR HERNANDO COUNTY STATE OF FLORIDA PROBATE DIVISION CASE NO: _______________________ STATE OF FLORIDA COUNTY OF HERNANDO IN RE: __________________________________________________ DECEASED AFFIDAVIT Before me the undersigned personally appeared _____________________________________ in __________________________________________________ where under oaths and all penalties of perjury, swore and affirmed as follows: NAME OF PETITIONER Name of Petitioner(s) _________________________________________________________________ Address ____________________________________________________________________________ Telephone Number ____________________________________________________________________ E-mail address _______________________________________________________________________ Social Security Number _______________________________________________________________ Relationship to the deceased ____________________________________________________________ DEATH CERTIFICATE Name of deceased ____________________________________________________________________ When did deceased pass _______________________________________________________________ Deceased residential address ____________________________________________________________ Has death certificate of deceased been filed Yes No If yes, when ______________________________ where _____________________________________ Is it attached to this petition? ____________________________________________________________ If no, why not _______________________________________________________________________ ____________________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com LAST WILL AND TESTAMENT Did the deceased have will ____________________________________________________________ If yes, have you found the last will ______________________________________________________ Are you sure you have found the last will _________________________________________________ If yes, when ______________________________ where _____________________________________ Is the will attached to this petition? ______________________________________________________ If no, why not _______________________________________________________________________ NO WILL Are you positive there is no will ________________________________________________________ Why are you so positive? _____________________________________________________________ HEIRS AT LAW List the names, address and approximate ages of the deceased spouse, children, and parents: Name Address Age ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ PROBATE OR ADMINISTRATION PLANNED If you are the personal representative named in the will or the surviving spouse or next of kin of the deceased, is any formal administration (of any type or form) of the estate of the deceased being contemplated? Yes No What is planned? ___________________________________ ____________________________________________________________________________________ If no, why not _______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com If no administration is planned, what do you request from the court? ____________________________________________________________________________________ ____________________________________________________________________________________ Why do you request this relief from the court? ____________________________________________________________________________________ ____________________________________________________________________________________ What authority do you have to request such relief? ____________________________________________________________________________________ ____________________________________________________________________________________ What is the amount of money (or value) involved that you desire a Letter issued on? ____________________________________________________________________________________ ____________________________________________________________________________________ Describe in detail the item(s) that you desire the Letter issued (provide complete description and your basis for requesting same, alone with name, address (local address if possible) and account number of recipient letter): ______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Are there any debts of the deceased: List of debts and amounts: No Yes _____________________________________________________ _____________________________________________________ Under penalties of perjury, I swear the above is true and correct. ______________________________________________ Affiant (Petitioner) (Signed before Clerk/Notary) STATE OF FLORIDA COUNTY OF HERNANDO The foregoing instrument was acknowledged before me this ________ day of _____________, 20 ______, who is personally known to me or who has produced ____________________________ as identification and who did take an oath. _______________________________________________ Deputy Clerk/ Notary Public ____________________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com