SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION Estate of Adm. No. Trust of TR. No. CLAIM AGAINST DECEDENT’S ESTATE and/or REVOCABLE TRUST The claimant named below certifies that (check the applicable box[es])  The claimant makes claim for_______________________________________.  The claimant makes claim for costs of administration of the settlor decedent’s estate in the amount of________________for____________________________.  The claimant makes claim for the expenses of the settlor decedent’s funeral and disposal of remains in the amount of____________________________________.  The claimant makes claim for the homestead allowance, or a portion thereof in the amount of_____________ ,as provided by D.C. Code § 19-101.02.  The claimant makes claim for the exempt property allowance, or a portion thereof in the amount of______________ , as provided by D.C. Code § 19-101.03.  The claimant makes claim for the family allowance, or a portion thereof in the amount of______________, as provided by D. C. Code § 19-101.04. On behalf of the claimant 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 and belief. Decedent died on ______________________ and was a resident of ________________ _________________________ Name of Claimant ________________________ _____________________________ Signature of claimant or person authorized to make verification on behalf of Claimant Address _____________________________________ _____________________________________ All claims presented to the Register of Wills must be accompanied by check or money order in the amount of $ 5.00. I hereby certify that I have delivered or mailed, return receipt requested, a copy hereof to the personal representative of the estate of______________________________________and/or___________________________ _____________________trustee of the revocable trust of________________________this_________day of___________, 200_. _________________ Claimant For Register of Wills Use Only Date Filed: By______________________ Deputy Register of Wills American LegalNet, Inc. www.FormsWorkflow.com