IN THE CIRCUIT COURT FOR HILLSBOROUGH COUNTY, FLORIDA PROBATE DIVISION IN RE: ESTATE OF FILE NO. __________ DIVISION__________ Deceased. STATEMENT OF CLAIM BY______________________ 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 name and address of the claimant are_____________________________________ ______________________________________________________________________ and the name and address of the claimants 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 _________________________. 4. The claim (is) (is not) contingent or unliquidated. If contingent or unliquidated, the nature of the uncertainty is ________________________________________________ ______________________________________________________________________.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. Signed on _________________, _______. _____________________________ ____________________________Attorney for Claimant ClaimantFlorida Bar No. ________________ Copy mailed to attorney for the_____________________________ Personal Representative on_____________________________ ______________________, __________________________________ CLERK OF THE CIRCUIT COURTTelephone:____________________ By:_________________________ MUST BE FILED IN DUPLICATE PROB093(10/23/02)