IN THE CIRCUIT COURT, TWENTIETH JUDICIAL CIRCUIT IN AND FOR LEE COUNTY, FLORIDA, PROBATE DIVISION IN RE: Estate of FILE NUMBER: DIVISION: Deceased DISPOSITION OF PERSONAL PROPERTY WITHOUT ADMINISTRATION Verified Statement , alleges: Petitioner, 1. Petitioner, whose address is of , is the (relationship to decedent) , , who died at (Name of decedent) on , a resident of Lee County, Florida, whose last known address was, and, if known, whose age was 2. . and whose social security number is The decedent died without a Will; The decedent's Will was deposited with the Clerk on . 3. So far as is known, the names of the beneficiaries of decedent's estate and of the decedent's surviving spouse, if any, their addresses and relationships to decedent, and the dates of birth of any who are minors are: Name Address Relationship Date of Birth (if Minor) American LegalNet, Inc. www.FormsWorkflow.com 4. The estate of decedent consists only of personal property exempt from the claims of creditors under the Constitution of Florida, and non-exempt personal property the value of which does not exceed the sum of the amount of preferred funeral expenses and reasonable and necessary medical and hospital expenses of the last 60 days of the decendent's last illness, all being described as follows: A. Exempt Property: List - Automobiles used by the deceased or members of the deceased's immediate family. Household furniture and furnishings not to exceed $10,000. Florida prepaid college tuition. Other items of personal property not to exceed $1,000 in value Description Value Total B. NON-EXEMPT: List - All other items of personal property owned by the deceased and their estimated value. Include the balance of items as stocks, bonds & accounts, name of institution, account number and other items of the deceased [not to exceed value of funeral or medical expenses]. Description Value Total American LegalNet, Inc. www.FormsWorkflow.com C. PREFERRED FUNERAL EXPENSES (List funeral, interment and grave marker expenses of up to $6,000, including the name of the services provider and whether the bill has been paid or not. (Attach statements or receipts): Services by Amount Type of Service Paid Due Total: D. MEDICAL AND HOSPITAL EXPENSES FOR LAST 60 DAYS OF LAST ILLNESS: List the provider and amount of all medical and hospital expenses during the deceased's last 60 days of the last illness, and whether the bill has been paid or not - Attach statements or receipts. Services by Type of Service Amount Paid Due Total: 5. Total of Items in paragraph B Total of Items in paragraph C Total of Items in paragraph D If the total of B is more than the total of paragraphs C and D, Do not continue as you are not eligable for Disposition Without Administration. If less, proceed with completion of the Application. OTHER DEBTS OF DECEDENT: List all other people or businesses which the deceased owed money to and the amount owed. Creditor Goods/Services (How incurred) Amount American LegalNet, Inc. www.FormsWorkflow.com REQUESTED PAYMENT OR DISTRIBUTION TO: (a) EXEMPT property should be listed and is to go to the deceased's spouse, if any, and if not to the deceased's children. (b) Payment of non-exempt property to party who paid expenses or to service provider if currently unpaid. (c) Payment of any debts of the deceased. (d) Any remaining personal property is to go to the deceased's beneficiaries. Name Property Value 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. Signature of Petitioner Address Telephone Sworn and subscribed to before me this _____ day of ___________________, 20___, who ___ is personally known or _____ produced identification. Type of Identification produced ____________________________________. Notary information My commission expires: Charlie Green, Clerk of the Circuit Court By: Deputy Clerk Notary signature Print Name American LegalNet, Inc. www.FormsWorkflow.com