DE-172 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address): TELEPHONE AND FAX NOS.: FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: ESTATE OF (Name): DECEDENT CREDITOR'S CLAIM CASE NUMBER: You must file this claim with the court clerk at the court address above before the LATER of (a) four months after the date letters (authority to act for the estate) were first issued to the personal representative, or (b) sixty days after the date the Notice of Administration was given to the creditor, if notice was given as provided in Probate Code section 9051. You must also mail or deliver a copy of this claim to the personal representative and his or her attorney. A proof of service is on the reverse. WARNING: Your claim will in most instances be invalid if you do not properly complete this form, file it on time with the court, and mail or deliver a copy to the personal representative and his or her attorney. 1. Total amount of the claim: $ 2. Claimant (name): an individual a. an individual or entity doing business under the fictitious name of (specify): b. c. a partnership. The person signing has authority to sign on behalf of the partnership. d. a corporation. The person signing has authority to sign on behalf of the corporation. e. other (specify): 3. Address of claimant (specify): 4. Claimant is the creditor a person acting on behalf of creditor (state reason): Claimant is the personal representative the attorney for the personal representative. 5. 6. I am authorized to make this claim which is just and due or may become due. All payments on or offsets to the claim have been credited. Facts supporting the claim are on reverse attached. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: . . . . . . . . . . . . . . . . . . . . . .. (TYPE OR PRINT NAME AND TITLE) (SIGNATURE OF CLAIMANT) INSTRUCTIONS TO CLAIMANT A. On the reverse, itemize the claim and show the date the service was rendered or the debt incurred. Describe the item or service in detail, and indicate the amount claimed for each item. Do not include debts incurred after the date of death, except funeral claims. B. If the claim is not due or contingent, or the amount is not yet ascertainable, state the facts supporting the claim. C. If the claim is secured by a note or other written instrument, the original or a copy must be attached (state why original is unavailable.) If secured by mortgage, deed of trust, or other lien on property that is of record, it is sufficient to describe the security and refer to the date or volume and page, and county where recorded. (See Prob. Code, § 9152.) D. Mail or take this original claim to the court clerk's office for filing. If mailed, use certified mail, with return receipt requested. E. Mail or deliver a copy to the personal representative and his or her attorney. Complete the Proof of Mailing or Personal Delivery on the reverse. F. The personal representative or his or her attorney will notify you when your claim is allowed or rejected. G. Claims against the estate by the personal representative and the attorney for the personal representative must be filed within the claim period allowed in Probate Code section 9100. See the notice box above. (Continued on reverse) Form Approved by the Judicial Council of California DE-172 [Rev. January 1, 1998] Mandatory Form [1/1/2000] CREDITOR'S CLAIM (Probate) Probate Code, §§ 9000 et seq., 9153 2001 © American LegalNet, Inc. ESTATE OF (Name): DECEDENT CASE NUMBER: FACTS SUPPORTING THE CREDITOR'S CLAIM Date of item See attachment (if space is insufficient) Item and supporting facts Amount claimed TOTAL: $ PROOF OF MAILING PERSONAL DELIVERY TO PERSONAL REPRESENTATIVE (Be sure to mail or take the original to the court clerk's office for filing) 1. I am the creditor or a person acting on behalf of the creditor. At the time of mailing or delivery I was at least 18 years of age. 2. My residence or business address is (specify): 3. I mailed or personally delivered a copy of this Creditor's Claim to the personal representative as follows (check either a or b below): Mail. I am a resident of or employed in the county where the mailing occurred. a. (1) I enclosed a copy in an envelope AND deposited the sealed envelope with the United States Postal Service with the postage fully prepaid. (a) placed the envelope for collection and mailing on the date and at the place shown in items below following (b) our ordinary business practices. I am readily familiar with this business' practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service in a sealed envelope with postage fully prepaid. (2) The envelope was addressed and mailed first-class as follows: (a) Name of personal representative served: (b) Address on envelope: (c) Date of mailing: (d) Place of mailing (city and state): b. Personal delivery. I personally delivered a copy of the claim to the personal representative as follows: (1) Name of personal representative served: (2) Address where delivered: (3) Date delivered: (4) Time delivered: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: . . . . . . . . . . . . . . . . . . . . . .. (TYPE OR PRINT NAME OF CLAIMANT) DE-172 [Rev. January 1,1998] (SIGNATURE OF CLAIMANT) CREDITOR'S CLAIM (Probate) Page two 2001 © American LegalNet, Inc.