Disposition Of Personal Property Without Administration Verified Statement

IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR LEE COUNTY, FLORIDA PROBATE DIVISION DISPOSITION OF PERSONAL PROPERTY WITHOUT ADMINISTRATION Date: In RE: Petitioner alleges at [Name of Decedent] [Today's Date] [Name of the Person Entitled to Out of Pocket Reimbursement] [Name of Decedent] died on [Date of Death] , 20 [Year] [Place of Decedent's Death] , whose address was [Last Known Address of Decedent] , a resident of Lee County at the time of death, The decedent left no will [Check Box for "Yes" Leave Blank for "No"] The decedent's will was deposited with the Clerk [Check Box for "Yes" Leave Blank for "No"] Names, addresses and ages of heirs-at-law and relationship to decedent: [Full Name, Address, Age & Relationship to the Decedent. Anyone listed must sign consent form] Example: Jane Smith, 122-6th St., Fort Myers, FL 33967- 22 yrs. old Personal Property of decedent: [List Personal Property Being Claimed ­ Current Value ­ Account Number] [If Police or Sheriff are Holding Property, a Copy of the Evidence Report] The following debts of decent have been paid: Funeral Expenses: [Amount Paid] ***Must Provide a Copy of the Bill and Canceled Check or Credit Card Receipt *** Medical and Hospital expenses of last 60 days of last illness: Others: Statement or receipt must be presented with the statement. Petitioner requests payment to be made to: [Same As Above] [Full Name, Street Address, City, State, Zip of the Person to Receive the Assets of the Deceased that is Entitled to Reimbursement] *** Even If Information is Duplicated *** I know of no other assets or debts of the decedent. [Check Box for "Yes"] Under penalties of perjury, I declare that the foregoing and the facts alleged are true to the best of my knowledge and belief. LINDA DOGGETT Clerk of the Circuit Court By: Signature of Claimant Deputy Clerk / Notary Address Telephone [Full Street Address] [City, Zip, State] [A/C Phone Number] [Original Signature of the Petitioner] My Commision Expires: SWORN TO AND SUBSCRIBED before me this ____ day of _________________, 20 _____ by: _________________ who is [ ] personally known to me or [ ] presented _______________________ as identification. P-63 (rev 12/10/01, 1/1/02, 01/2005) American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR LEE COUNTY, FLORIDA PROBATE DIVISION DISPOSITION OF PERSONAL PROPERTY WITHOUT ADMINISTRATION Date: In RE: Petitioner alleges at , a resident of Lee County at the time of death, died on , whose address was , 20 The decedent left no will The decedent's will was deposited with the Clerk Names, addresses and ages of heirs-at-law and relationship to decedent: Personal Property of decedent: The following debts of decent have been paid: Funeral Expenses: Medical and Hospital expenses of last 60 days of last illness: Others: Statement or receipt must be presented with the statement. Petitioner requests payment to be made to: I know of no other assets or debts of the decedent. Under penalties of perjury, I declare that the foregoing and the facts alleged are true to the best of my knowledge and belief. LINDA DOGGETT Clerk of the Circuit Court By: Deputy Clerk / Notary Signature of Claimant Address Telephone P-63 (rev 12/10/01, 1/1/02, 01/2005) American LegalNet, Inc. www.FormsWorkFlow.com My Commision Expires: SWORN TO AND SUBSCRIBED before me this ____ day of _________________, 20 _____ by: _________________ who is [ ] personally known to me or [ ] presented _______________________ as identification.