SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION Trust of ________________________________ Settlor _________ NRT _________ __________ ADM _________ Estate of ________________________________ Deceased CLAIM AGAINST REVOCABLE TRUST The claimant named below certifies that [ ] 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, sec. 19-101.02. [ ] The claimant makes claim for the family allowance, or a portion thereof in the amount of $________________________, as provided by D.C. Code, sec. 19-101-04. [ ] The claimant makes claim for the exempt property allowance, or a portion thereof in the amount of $______________________, as provided by D.C. Code, sec. 19-101.03. [ ] This claim is also a claim against the settlor decedent’s estate, estate number _______ ADM ______. (Note that two claim forms must be filed.) Decedent died on ___________________and was a resident of ______________________. (date of death) VERIFICATION On behalf of the claimant named below, I ____________________________, being first duly sworn, on oath, depose and say that I have read the foregoing claim by me subscribed Jan. 2010 American LegalNet, Inc. www.FormsWorkFlow.com and that the facts therein stated are true to the best of my knowledge, information, and belief. ____________________________________ Name of claimant ____________________________________ Address (Actual address/not Post Office Box) _____________________________________ Signature of claimant or person authorized to make verification on behalf of claimant ____________________________________ ___________________________________ Telephone number Subscribed and sworn to before me this ____ day of _________________, 20__. _________________________________ Notary Public/Deputy CERTIFICATE OF SERVICE I hereby certify that on the _____ day of ________________, 20__, a copy of the foregoing claim was delivered or mailed, return receipt requested, to ______________________________________, Trustee of the revocable trust of ______________________________________________________. _______________________________ Signature All claims presented to the Register of Wills must be accompanied by check or money order in the amount of $5.00, payable to the “Register of Wills.” Jan. 2010 American LegalNet, Inc. www.FormsWorkFlow.com