Superior Court of the District of Columbia PROBATE DIVISION ADMINISTRATION NO. ________________________S.E. ______________________________________________________ Name of Decedent STATEMENT OF CLAIMS The Notice to Creditors and all interested persons has been duly published in _______________________________________ as shown by the attached Affidavit Publication; the time of filing has expired; funeral expenses in the amount $__________________________ have been paid; and all creditors now known to undersigned, including contingent and disputed claims, are as follows: Name of Creditor Nature of Claim the of of the Amount I do solemnly declare and affirm under penalty of law that the contents of the foregoing document are true and correct to the best of my knowledge, information and belief. __________________________________________ Personal Representative American LegalNet, Inc. www.USCourtForms.com