IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR LEE COUNTY, FLORIDA PROBATE DIVISION IN RE: The Estate of Case Number: 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 claimant is: and the names and addresses of the claimant's agent or attorney, if any, are: 3. The amount of the claim is $___________________ which amount is now due and owing, or, if not due, will become due on _______________________, 20_____. 4. The claim is is not contingent. If contingent, the nature of the contingency 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. Executed this _____ day of __________________, 20_____. Signature of Claimant American LegalNet, Inc. www.FormsWorkFlow.com