JOSEPH E. SMITH Clerk of the Circuit Court, St. Lucie County Probate & Guardianship Department 201 S. Indian River Dr., 3rd Floor Fort Pierce, FL 34950 (772) 462-6920 Mailing Address: P.O. Box 700 Fort Pierce, FL 34954 Per Florida Statute 733.702, all claims must be filed no later than 3 months after the time of the first publication of notice to creditors. For each served creditor, 30 days after the date of service on the creditor. Per your request regarding the Statement of Claim: INSTRUCTIONS 1. Inapplicable words or statements may be stricken, but all information indicated in the form must be given. 2. The nature and extent of the claim should be stated in the spaces provided in sufficient detail to advise the personal representative of the estate of full particulars in order that the validity of the claim may be determined. 3. For questions 4, a contingent claim means that the total amount of the claim cannot be determined until a later date. 4. For question 5, a secured claim would be determined if there were property or collateral held against the claim. 5. An exact copy of this claim must be filed with the Clerk of the Court at the time of filing. American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE NINETEENTH JUDICAL CIRCUIT, IN AND FOR ST. LUCIE COUNTY, FLORIDA RE: ESTATE OF _________________________ __________________________________/ Deceased FILE NO: Division: _________________________ 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 is: ____________________________________________ ______________________________________________________________________________and the name and address of the claimant's attorney, if any are: _________________________ ______________________________________________________________________________ 3. The amount of the claim is $_______________________________________________________ which amount is now due and owing, or, if not due, will become due on _____________, 20____ 4. The claim (is) (is not) contingent. If contingent, the nature of the contingency is: ____________ ____________________________________________________________________________________ ________________________________________________________________________ 5. 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 _______________, 20_____ ______________________________________ Claimant Copies provided to interested parties on _____________. JOSEPH E. SMITH, CLERK OF THE CIRCUIT COURT No.___________________________ ______________________________________ Attorney for Claimant Florida Bar Address: _______________________________ ______________________________________ By ____________________________________________ Deputy Clerk Telephone: _____________________________ American LegalNet, Inc. www.FormsWorkFlow.com