SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ ADM _________ Estate of ________________________________ Deceased _________ SEB _________ _________ FEP _________ NOTICE OF ACTION TAKEN ON CLAIM To ________________________________________ : (Claimant) You are hereby notified that your claim in the amount of $ ____________________________ against the above entitled estate is Allowed in the stated amount. Allowed in the amount of $ _______________ . Disallowed in the stated amount. Disallowed in the amount of $ _____________ . Undetermined in the amount of $ ___________ and will be presented to the Court for determination. * Date Mailed or Delivered: ________________ ___________________________________ Signature ___________________________________ Typed name ___________________________________ Address (actual address/not Post Office Box) ___________________________________ ___________________________________ ___________________________________ Telephone number ___________________________________ Email address __________________________________ Bar number (if filer is an attorney) January 2014 � 121.10.v2 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE If your claim has been disallowed in whole or in part, it will be barred to the extent of its disallowance unless you file a verified complaint with the Probate Division of this Court within sixty days after the date of mailing of the notice disallowing the claim pursuant to D.C. Code, sec. 20-908(a). * If the action indicated above has not been instituted within eight months of the date of the first publication of notice of the appointment of the Personal Representative, you should file a verified complaint pursuant to D.C. Code, sec. 20-908(b) in the Probate Division of this Court. Please note: A copy of this form must also be filed with the Probate Division. January 2014 � 121.10.v2 American LegalNet, Inc. www.FormsWorkFlow.com