For your convenience, you may print this creditor222s Statement of Claim form, shown below, and mail to our office for filing. There is no fee to file this form. Florida Probate Rule 5.490 requires that the Claim be filed in duplicate with one copy containing an original signature. The clerk will mail the copy of the claim to the Attorney for the Personal Representative. American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT FOR COUNTY, FLORIDA CASE NO. IN RE: ESTATE OF: 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 of the Claimant are and the name and address of the claimant222s attorney, if any, are 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 unliquidated. If contingent or unliquidated the nature of the uncertainty is 5. The claim (is) (is not) secured. If secured, the security consists of CLERK222S USE ONLY Under penalties of perjury, I declare that I have I hereby certify that a copy of the Statement read the foregoing, and the facts alleged are true, Of Claim has been mailed to the foregoing on to the best of my knowledge and belief. Signed on Attorney Claimant CLERK OF CIRCUIT COURT Attorney for Claimant COUNTY, FLORIDA Florida Bar # By: Telephone Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com