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BROWSE PINELLAS COUNTY CLERK OF THE CIRCUIT COURT AND COMPTROLLER FORMS

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For your convenience, you may print the creditor’s Statement of Claim form shown
below and mail it to our office for filing. There is a $2 fee to file this form. The claim
may only be filed into an existing Estate case. Please include the case number or
reference number on your claim form. Florida Probate Rule 5.490 requires that the
Claim be filed in duplicate with one copy containing an original signature. The clerk
will mail the copy of the claim to the Attorney for the Personal Representative.
IN THE CIRCUIT COURT FOR
______________ COUNTY, FLORIDA
CASE NO.___________________
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 the Claimant are_________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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, or, if not due, will become due on ______________________________________________________
4. The claim (is) (is not) contingent or unliquidated. If contingent or unliquidated the nature of
the uncertainty is _______________________________________________________________________
______________________________________________________________________________________
5. The claim (is) (is not) secured. If secured, the security consists of ______________________
______________________________________________________________________________________
CLERK’S USE ONLY Under penalties of perjury, I declare that I have
I hereby certify that a copy of the Statement read the foregoing, and the facts alleged are true,
Of Claim has been mailed to the foregoing on to the best of my knowledge and belief.
_____________________________________ Signed on__________________________________
Attorney ___________________________________________
______________________________________ Claimant
______________________________________ ___________________________________________
CLERK OF CIRCUIT COURT Attorney for Claimant
________________COUNTY, FLORIDA Florida Bar #________________________________
By: ____________________________________ Telephone __________________________________
Deputy Clerk
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Completed 10 February 2021

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