IN THE CIRCUIT COURT FOR SARASOTA COUNTY, FLORIDA PROBATE DIVISION IN RE: ESTATE OF FILE NO: DECEASED DIVISION: STATEMENT OF CLAIM The undersigned hereby presents for filing against the above estate this statement of claim and alleges: 1. The basis for the claim is . 2. The Social Security Number or Tax Identification Number of the claimant is . The name and address of the claimant are: 3. The amount of the claim is $ , which is now due, or if not due will become due on , 2. 4. The claim (is) (is not) contingent or unliquidated. If contingent or unliquidated, the nature of the uncertainty 5. is 6. 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 2 . (Attorney for Claimant) (Claimant) Florida Bar No. Copy mailed to attorney for the personal representative on , 2 KAREN E. RUSHING, CLERK CLERK OF THE CIRCUIT COURT (Address) BY: DEPUTY CLERK MUST BE FILED IN DUPLICATE. SEE REVERSE SIDE FOR IMPORTANT INFORMATION. American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com