SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ SEB _________ Estate of ________________________________ Deceased STATEMENT OF CLAIMS The Notice of Appointment, Notice to Creditors and Notice to Unknown Heirs has been duly published in the ___________________________ as shown by the attached Affidavit of Publication; the time for filing claims has expired; funeral expenses in the amount of $_____________________ have been paid; and all creditors now known to the undersigned, including contingent and disputed claims are as follows: Name of Creditor Nature of Claim 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(s) American LegalNet, Inc. www.FormsWorkFlow.com Feb. 2009