State of Minnesota County Judicial District: Court File Number: Case Type: District Court In the Matter of the Estate of: WRITTEN STATEMENT OF CLAIM , (Full Name) Decedent STATE OF MINNESOTA COUNTY OF ) ) SS ) 1. My name is: ______________________________________________________ and I have a valid claim against this estate. 2. My address and telephone number are: _______________________________________ _______________________________________________________________________. 3. The Estate is or will become indebted to me in the amount of $_____________________. 4. The nature of the claim is: _________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________. 5. The claim arose prior to the death of the Decedent on or about____________________ or after the death of the Decedent, on or about ____________________. unsecured, or 6. The claim is secured by: ______________________________________________ _______________________________________________________________________. 7. The claim is is not based on a contract which makes a provision for interest. 8. The claim was or will be due and payable on __________________________________. 9. If the claim is contingent or unliquidated, the nature of the uncertainty is as follows: ___ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________. 10. Under penalties for perjury, I declare that I have read this document and I know or believe its representations are true and complete. Dated: Signature Name: Street Address: City/State/Zip: E-mail address: PRO402 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com