CIRCUIT COURT, PINELLAS COUNTY, FLORIDA PROBATE DEPARTMENT IN RE: ________________________ DATE _________________ Deceased UCN: ________________ REF #: ________________ DISPOSITION OF PERSONAL PROPERTY WITHOUT ADMINISTRATION U Petitioner, _____________________________________________, alleges: 1. Petitioner, whose address is __________________________________ ____________________________________________________________, and is ________________ of ____________________________________ (relationship to decedent) (decedent name) who died at ____________________________, on _____________, 20__, (place of death) (date of death) a resident of ___________________, whose last known address was (county of domicile) ___________________________________________________________________ ___________________________________________________________________ and if known, whose age was _________ and whose social security number is ______________________. The decedent left no will. The decedent’s will was deposited with the Clerk on ____________, 20___. 2. 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 relationship to decedent, and the ages of any who are minors, are: NAME ADDRESS RELATIONSHIP AGE (date of birth if minor) P-63 (rev 12/10/01, 1/1/02, 01/2005, 3/2005) American LegalNet, Inc. www.FormsWorkflow.com 3. Personal Property of decedent: (solely owned asset(s)), the value of which does not exceed the sum of the amount paid out of pocket for funeral expenses and reasonable and necessary medical/hospital expenses of the last 60 days of the decedent’s last illness, as described below: Description of asset(s) Value The following debts of decedent 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. I know of no other assets or debts of the decedent. Petitioner requests that the Court issue a letter or other writing under the seal of the Court authorizing payment, transfer or disposition of the property to: Name Asset Amount or Value Under penalties of perjury, I declare that the foregoing and the facts alleged are true to the best of my knowledge and belief. Signature of Petitioner Address Telephone P-63 (rev 12/10/01, 1/1/02, 01/2005, 3/2005) American LegalNet, Inc. www.FormsWorkflow.com