Statement Of Claim printable pdf download

Statement Of Claim

IN THE COURT FOR INDIAN RIVER COUNTY, FLORIDA

PROBATE DIVISION

CASE NUMBER __________________________________ CP

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 claimant is: ______________________________________________________________

_______________________________________________________________________________________________

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 the 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

COPY MAILED TO ATTORNEY OF RECORD

on _______________________________, 20_____.

CLERK OF THE CIRCUIT COURT

By_______________________________________

MUST BE FILED IN DUPLICATE. SEE REVERSE SIDE FOR IMPORTANT INFORMATION.

Revised: 09/12/2002

Statement Of Claim