I-G SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION IN RE: Intervention Proceeding No.________________ ____________________________________ An Adult STATEMENT OF CLAIM PURSUANT TO SCR-PDIP 307 Name, address and telephone number of claimant: ____________________________________________________________________________ ____________________________________________________________________________ Amount of Claim: _____________________________________________________________ (Attach supporting documents) ____________________________________________________________________________ ____________________________________________________________________________ Name, address and telephone number of attorney for claimant: ____________________________________________________________________________ ____________________________________________________________________________ _______________________________ Signature of Claimant CERTIFICATE OF SERVICE I hereby certify that a copy of the foregoing statement of claim was delivered/mailed by first class mail postage prepaid to __________________________________ conservator herein. ______________________________ Signature of Claimant __________________________ Date Mailed American LegalNet, Inc. www.USCourtForms.com