Name of Person Filing: ________________________________________ Mailing Address: ________________________________________ City, State, and Zip Code: ________________________________________ Daytime Phone Number: ________________________________________ State Bar Number (if applicable):______________________________________ Self (no Attorney) or Represented by: Attorney For Clerk’s Use Only SUPERIOR COURT OF ARIZONA MOHAVE COUNTY In the Matter of the Estate of Case Number: ________________________ CLAIM AGAINST THE ESTATE _______________________________________ an Adult a Minor, deceased 1. My name and address is ______________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2. The Estate is indebted to me in the amount of $_______________________ 3. The basis of my claim is: ______________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ (NOTE: Complete number 4 or 5 only if either apply to your claim.) 4. The claim is not yet due. It will become due on (date) _______________________________________ 5. The claim is secured by the following property (describe): ____________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 6. I am mailing a copy of the Claim Against the Estate to the Personal Representative, if one has been appointed. DATED this ______________ day of __________________ 20______ ____________________________________________ Signature ____________________________________________ Print Name Revised: 4/14/2011 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com