IN THE CIRCUIT COURT OF THE SECOND JUDICIAL CIRCUIT, IN AND FOR LEON COUNTY, FLORIDA RE: ESTATE OF _________________________________/ Deceased FILE NO:_____________ DISPOSITION OF PERSONAL PROPERTY WITHOUT ADMINISTRATION VERIFIED STATEMENT The Petitioner, ______________________________________, whose relationship to the decedent is ______________, alleges that ________________________________________, a resident of Leon County, who's Social Security Number was ________________________ and whose last known address was_______________________________________________________________, died on _________________________,___________. _________ The decedent left no will. _________ The decedent's will was deposited with the clerk on ____________,______. The property of the decedent which must be transferred consists only of personal property exempt under the provisions of s. 732.402, personal property exempt from the claims of creditors under the Constitution of Florida, and nonexempt 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 last illness. Please supply information to be used in the transfer of these assets. Give name of bank, transfer agent, or company handling the asset(s). These assets are: ASSETS DESCRIPTION ADDRESS OF FIDUCIARY DOLLAR AMOUNT ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Funeral or burial expenses (attach statement and/or receipts); SERVICES BY ADDRESS AMOUNT PAID OR DUE American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Last illness expenses (statement and/or paid receipt attached): SERVICES BY ADDRESS TYPE OF SERVICE AMOUNT PAID? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Petition requests payment or distribution to: NAME ADDRESS ASSET VALUE ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I know of no other assets in the decedent's name alone except: ______________________________________________________________________________ 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. DATE:__________________________ __________________________________ Signature of Petitioner __________________________________ Name of Petitioner (Print Name) Statement obtained by: ______________________ Deputy Clerk _________________________________ Address __________________________________ City State Zip __________________________________ (Area Code) Telephone Number __________________________________ Relationship to Decedent American LegalNet, Inc. www.FormsWorkflow.com