Estate of First, middle, and last name I, Creditor222s name of Address submit the following claim against the estate for the sum set forth.* DESCRIPTION OF CLAIMAMOUNT There is now due on the claim, above all legal setoffs, the sum of: þ Notice to interested persons: This is a claim by a personal representative for an obligation that arose before the death of the þ decedent. Upon petition and notice to interested persons, a hearing will be held to determine whether to allow the claim. You þmay object to the claim before or at the hearing. I declare under the penalties of perjury that this statement and proof of claim has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Attorney signature þ Date Name (type or print) Bar no. þ Claimant signature Address þ Address City, state, zip Telephone no. þ City, state, zip Telephone no. * þ 1. þ Describe nature of claim or attach a statement. Attach copy of receipt or other evidence of payment if submitted by þþ assignee. þ 2. þ Claims must be presented either personally or by mail to the fiduciary on or before the last day for presentment of claims. þ This claim may also be filed with the probate court (see reverse side for proof of service). (SEE SECOND PAGE)USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form. American LegalNet, Inc. www.FormsWorkFlow.com File No. I served upon Name ,fiduciary, a copy of this statement and proof of claim on Date by State method and address of service .I declare under the penalties of perjury that this proof of service has been examined by me and that its contents are true to thebest of my information, knowledge, and belief. Date þ Signature Service of the attached statement and proof of claim is acknowledged. Date þ Signature PROOF OF SERVICE ACKNOWLEDGMENT OF SERVICE American LegalNet, Inc. www.FormsWorkFlow.com