IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT OF THE STATE OF FLORIDA, IN AND FOR HILLSBOROUGH COUNTY PROBATE AND MENTAL HEALTH DIVISION IN RE: CASE NO.____________________________ DIVISION____________________________ DATE: ____________________________ Deceased DISPOSITION OF PERSONAL PROPERTY WITHOUT ADMINISTRATION (Verified Statement) Petitioner, _____________________________________________________________ alleges: 1. Petitioner, whose address is __________________________________________________________ _____________________________________________________________________________________________ and is______________________, of________________________________________________________________ _____________________________________ who died at __________________________________________on the _________ day of_______________________, 20 ____, a resident of _________________, whose last known address was ______________________________________________________________________________, and, if known, whose age was ________ and whose social security number is ______________________________. [ ] The decedent left no will. [ ] The decedents will was deposited with the clerk on ____________________, 20 ____. 2. So far as is known, the namesofthe beneficiariesofdecedentsetate and of the decedents surviving spouse,sif any, their addresses and relationship to decedent, and the ages of any who are minors, are: NAME ADDRESS RELATIONSHIP AGE (Birth Date if Minor) 3. The estate of decedent consistsonlyofpersonalpropertyexemptundertheprovisionsofSection732.402of theFlorida Probate Code, personal property exempt from theclaimsofcreditorsunder the Constitution of Florida, and nonexemptpersonal property thevalue of which does not exceed the sum of the amount of preferred funeral expenses and reasonable andPRO076(02-12-98) Page 1 of 3>>>> 2necessary medical and hospital expenses of the last 60 days of the decedents last illness, all being described as follows: Description Value EXEMPT: NON-EXEMPT: Preferred funeral expenses (statement or receipt attached): Services by Amount Paid or DueMedical and hospital expenses for last 60 days of last illness (statement or receipt attached): Services by Type of Service Amount Paid or DueOther debts of decedent: Creditor Goods or Services (How incurred) AmountPRO076(02-12-98) Page 2 of 3 >>>> 3Petitioner requests that the Court issue a letter or other writing under the seal of the Court authorizing payment, transfer, or disposition of the property to: Name Property Amount or ValueI know of no other assets or debts of the decedent except: ____________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Underpenaltiesof perjury,IdeclarethatI haveread theforegoingand thefactsallegedare true, to the best of myknowledge and belief. ______________________________________________________________ Signature of Petitioner ______________________________________________________________ Name of Petitioner ______________________________________________________________ Address Telephone:_______________________________ Sworn to and subscribed before me this __________ day of ____________________________, 20 ______. CLERK OF CIRCUIT AND COUNTY COURTS By: ________________________________________________ Deputy ClerkPRO076(02-12-98) Page 3 of 3