Last updated: 5/2/2006
Statement Of Claim
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Description
IN THE CIRCUIT COURT, SEVENTH JUDICIAL CIRCUIT IN AND FOR VOLUSIA COUNTY, FLORIDA PROBATE DIVISION IN RE: Estate of FILE NUMBER: ____________________ D IVISION: 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 claimant is: ____________________________________________ ________________________________________________________________________ ___ ________________________________________________________________________ __; and the name and address of the claimants agent or 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 ________________. 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 best of my knowledge and belief. Executed this _______ day of _________________________, 2004. _________________________________ Claimant Copy mailed to the attorney/petitioner for the estate/guardianship on _________ _______, 2004. DIANE M. MATOUSEK CLERK OF CIRCUIT COURT By: Correspondence Clerk American LegalNet, Inc.CL -0014-0401 www.USCourtForms.com
