Estate No. Date In the Estate of: Date of Death CLAIM AGAINST DECEDENT'S ESTATE The claimant certifies that there is due and owing by the decedent in accordance with the attached statement of account or other basis for the claim the sum of $ . I solemnly affirm under the penalties of perjury that the contents of this document are true to the best of my knowledge, information and belief. Name of Claimant Signature of claimant or person authorized to make verifications on behalf of claimant Name and Title of Person Signing Claim Address Telephone Number CERTIFICATE OF SERVICE I hereby certify that on this day of (month), (year), ¨ I delivered or ¨ mailed, first class, postage prepaid a copy of this Claim to the personal representative, (name and address) Signature of Claimant Instructions: 1. This form may be filed with the Register of Wills upon payment of the filing fee of $3.00, as provided by law. A copy must also be sent to the personal representative by the claimant. 2. If a claim is not yet due, indicate the date when it will become due. If a claim is contingent, indicate the nature of the contingency. If a claim is secured, describe the security. RW1128 Rev. 01/01/2016 American LegalNet, Inc. www.FormsWorkFlow.com ROWNET PDF