FORM #556GC (01/2019) 62-5-426, 62-5-433 STATE OF SOUTH CAROLINA ) ) COUNTY OF ) ) ) IN THE MATTER OF: ) PROBATE COURT USE ONLY , ) ) IN THE PROBATE COURT a protected person. ) ) CASE NUMBER - GC - - ) ) Date of a pp ointment of Conservator ( if known ): Mailing Address: Creditor: Address: Telephone: Email: Original Creditor: Address ( if different from above ) : Claim Amount Due: $ Account Number: Other Reference Number: Basis of claim ( e.g., c ontract , services r endered for protected person ) : Date claim will become due ( if not already due ) : Nature of uncertainty as to the claim, if any (i.e. , contingent claim, amount of claim, due date ): Description of security as to the claim, if any ( i.e., c ollateral for the debt ) : Executed this day of , 20. Signature: Print Name: Address: Preferred Telephone: Secondary Telephone: Email: INSTRUCTIONS: The original claim MUST be delivered or mailed to the Conservator for the Protected Person and may also be filed with the Probate Court of the county in which the conservatorship is under administration (see S.C. Code Ann. 247 62-5-426). Satisfaction or withdrawal of claim (Form #559GC) may be filed with the Court once the claim is resolved. American LegalNet, Inc. www.FormsWorkFlow.com