IN THE SEVENTEENTH JUDICIAL CIRCUIT, IN AND FOR
BROWARD COUNTY, FLORIDA
In Re: Estate of Case No.: _____________________
_________________________________ Judge: ________________________
AFFIDAVIT CONCERNING CRIMINAL HISTORY
This affidavit must be filed by all Personal Representatives and Petitioners in all testate and
intestate cases, formal and summary administrations.
I, _____________________________________________________, swear or affirm:
______ I certify that I have not been convicted of a felony.
(initial)
______ I certify that I have been convicted of a felony. List offense, date of conviction,
(initial)
court and case number, state and county of the court, regardless of whether adjudication
was entered or withheld.
Offense(s) _______________________________________________________________
Date(s) of conviction
Court & case number
State & County of the court
UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT I HAVE READ THE
FOREGOING AFFIDAVIT CONCERNING CRIMINAL HISTORY AND THE FACTS STATED
HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
_____________________________
Affiant’s signature
_____________________________
_____________________________
_____________________________
Print name and address of Affiant
State of _____________________
County of _____________________
Sworn to (or affirmed) and subscribed before me by means of ____ physical presence or ____ online
notarization, this day of__________________, 20 , by .
________________________________
Notary Public or Deputy Clerk
_____ Personally known
_____ Produced identification
Print, Type, or Stamp Commissioned
Name of Notary Public or Deputy Clerk
Type of identification: _______________________________
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