IN THE CIRCUIT COURT FOR ORANGE COUNTY, FLORIDA PROBATE MENTAL HEALTH DIVISION IN RE: ESTATE OF _____________________________/ Deceased CASE NUMBER: STATEMENT OF CLAIM The undersigned herby 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 claimant's 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 un-liquidated. If contingent or un-liquidated, the nature of the uncertainty is _____________________________________________________ ________________________________________________________________________ 5. The claim (is) (is not) secured. If secured, the security consist 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 _______________________________ Claimant Florida Bar No.__________________ _______________________________ _______________________________ Address Copy mailed to attorney for the Personal Representative on __________________ CLERK OF THE CIRCUIT COURT By:______________________________ Telephone:______________________ MUST BE FILED IN DUPLICATE American LegalNet, Inc. www.FormsWorkflow.com