IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR LEE COUNTY, FLORIDA PROBATE DIVISION DISPOSITION OF PERSONAL PROPERTY WITHOUT ADMINISTRATION Date: In RE: Petitioner alleges at [Name of Decedent] [Today's Date] [Name of the Person Entitled to Out of Pocket Reimbursement] [Name of Decedent] died on [Date of Death] , 20 [Year] [Place of Decedent's Death] , whose address was [Last Known Address of Decedent] , a resident of Lee County at the time of death, The decedent left no will [Check Box for "Yes" Leave Blank for "No"] The decedent's will was deposited with the Clerk [Check Box for "Yes" Leave Blank for "No"] Names, addresses and ages of heirs-at-law and relationship to decedent: [Full Name, Address, Age & Relationship to the Decedent. Anyone listed must sign consent form] Example: Jane Smith, 122-6th St., Fort Myers, FL 33967- 22 yrs. old Personal Property of decedent: [List Personal Property Being Claimed ­ Current Value ­ Account Number] [If Police or Sheriff are Holding Property, a Copy of the Evidence Report] The following debts of decent have been paid: Funeral Expenses: [Amount Paid] ***Must Provide a Copy of the Bill and Canceled Check or Credit Card Receipt *** Medical and Hospital expenses of last 60 days of last illness: Others: Statement or receipt must be presented with the statement. Petitioner requests payment to be made to: [Same As Above] [Full Name, Street Address, City, State, Zip of the Person to Receive the Assets of the Deceased that is Entitled to Reimbursement] *** Even If Information is Duplicated *** I know of no other assets or debts of the decedent. [Check Box for "Yes"] Under penalties of perjury, I declare that the foregoing and the facts alleged are true to the best of my knowledge and belief. LINDA DOGGETT Clerk of the Circuit Court By: Signature of Claimant Deputy Clerk / Notary Address Telephone [Full Street Address] [City, Zip, State] [A/C Phone Number] [Original Signature of the Petitioner] My Commision Expires: SWORN TO AND SUBSCRIBED before me this ____ day of _________________, 20 _____ by: _________________ who is [ ] personally known to me or [ ] presented _______________________ as identification. P-63 (rev 12/10/01, 1/1/02, 01/2005) American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR LEE COUNTY, FLORIDA PROBATE DIVISION DISPOSITION OF PERSONAL PROPERTY WITHOUT ADMINISTRATION Date: In RE: Petitioner alleges at , a resident of Lee County at the time of death, died on , whose address was , 20 The decedent left no will The decedent's will was deposited with the Clerk Names, addresses and ages of heirs-at-law and relationship to decedent: Personal Property of decedent: The following debts of decent have been paid: Funeral Expenses: Medical and Hospital expenses of last 60 days of last illness: Others: Statement or receipt must be presented with the statement. Petitioner requests payment to be made to: I know of no other assets or debts of the decedent. Under penalties of perjury, I declare that the foregoing and the facts alleged are true to the best of my knowledge and belief. LINDA DOGGETT Clerk of the Circuit Court By: Deputy Clerk / Notary Signature of Claimant Address Telephone P-63 (rev 12/10/01, 1/1/02, 01/2005) American LegalNet, Inc. www.FormsWorkFlow.com My Commision Expires: SWORN TO AND SUBSCRIBED before me this ____ day of _________________, 20 _____ by: _________________ who is [ ] personally known to me or [ ] presented _______________________ as identification.