SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ ADM _________ _________ SEB _________ _________ FEP _________ Estate of ________________________________ Deceased CLAIM AGAINST THE DECEDENT'S ESTATE The creditor named below certifies that there is owing by ___________________________________, deceased, Case No. _____________________, in accordance with the statement of account attached hereto as a part hereof, the sum of _____________________________________________________ ($______________________________________), together with interest at the rate of _______ from _____________________ until paid, and that the aforesaid account is correct as stated and is unpaid * ________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ On behalf of the creditor named below, I do solemnly declare and affirm under penalty of law that the contents of the foregoing document are true and correct to the best of my knowledge, information, and belief. Decedent died on ___________________and was a resident of ______________________________. (date of death) Name of Creditor: _____________________ ____________________________________ Address:_____________________________ ____________________________________ Phone No.:___________________________ INSTRUCTIONS * In addition to completing all pertinent blank spaces on the form, the claimant shall use these lines to state: 1. The due date if the claim is not yet due; 2. The nature of the contingency, if the claim is contingent; 3. The description of the security, if the claim is secured; 4. Nature of claim. All claims presented to the Register of Wills must be accompanied by check or money order in the amount of $5.00, payable to the "Register of Wills." I hereby certify that I have delivered or mailed, return receipt requested, a copy hereof to _________________________________________________ (personal representative or attorney) this ________ day of _________________________, 20___. _______________________________ Claimant _____________________________________ Signature of Creditor or person authorized to make verification on behalf of creditor June 2010 ­ 110.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com