DEBTOR'S STATEMENT - SECTION 1355.001 CAUSE NO. ____________ FOR THE USE AND BENEFIT OF: } { IN THE COUNTY COURT AT LAW { } ______________________________ } { NUMBER _______OF FORT BEND COUNTY, TEXAS GREETINGS: COMES NOW ______________________________________ hereinafter called DEBTOR, whose address is _______________________________________________________________ and hereinafter tenders to the County Clerk of Fort Bend County, Texas in accordance with the Terms and Provisions of Section 1355.001 Texas Estates Code, the sum of $_____________, being not more that $100,000.00 as specified by statute, for the use and benefit of ______________________________________, whose address is _________________________ ________________________________________________________________, hereinafter called CREDITOR. DEBTOR states that CREDITOR is a resident of Fort Bend County, Texas; is without a legal guardian of his/her person or estate; and is a ____________________________, date of birth _______________. DEBTOR states that said sum of money above tendered is the amount due to CREDITOR on a liquidated and uncontested Claim against DEBTOR arising out of the following transaction: DEBTOR requests the DEBTOR be issued a Receipt of said Clerk for said sum of money so tendered herewith in accordance with the Terms and Provisions of Section 1355.001 Texas Estates Code; and further that said CREDITOR be advised as required by law. WITNESS MY HAND ON ________ day of ________________, ________. DEBTOR SUBSCRIBED AND SWORN TO BEFORE ME on _________ day of _______________, ________. Notary Public in and for the State of Texas American LegalNet, Inc. www.FormsWorkFlow.com