IN THE FIFTH CIRCUIT COURT IN AND FOR HERNANDO COUNTY, FLORIDA CASE NO.: _______________________ DIVISION: PROBATE IN RE: ESTATE OF: ____________________________________________________ Deceased STATEMENT OF CLAIM The undersigned hereby presents for filing against the above estate this statement of claim and alleges: 1. The basis of the claim is: ____________________________________________________ _________________________________________________________________________ ________________________________________________________________________. 2. The name and address of claimant is: __________________________________________ ________________________________________________________________________. and the names and addresses of the claimant's agent or attorney, if any, are ___________ _______________________________________________________________________, The amount of the claim is $ ______________ which amount is now due and owing, or, if not due, will become due on __________________________________________, 20 __________ . The claim (is) (is not) contingent. If contingent, the nature of the contingency is ________ _______________________________________________________________________________ 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 DON BARBEE, JR CLERK OF THE CIRCUIT COURT By: ____________________________________ Deputy Clerk 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 stated in the spaces provided in sufficient detail to advise the personal representative of the estate of the full particulars in order that the validity of the claim may be determined. 2. An original and one copy of this claim must be submitted to 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 an objection is filed, a law suit in a court of competent jurisdiction must be filed within the time allowed by law, or this claim will be barred. See §733.702, Florida Statutes. Even if no objection is filed, a claim will be barred at the expiration of one (1) year from the date the claim is filed if the claim has not been paid, settled, or otherwise disposed of, and no proceeding is then pending for the enforcement of compulsory payment of it. See §733.710, Florida Statutes. American LegalNet, Inc. www.FormsWorkFlow.com