IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI - PROBATE DIVISION AT IN THE ESTATE OF ESTATE NUMBER , Deceased. Protectee. CLAIM AGAINST ESTATE (Sec. 473.360 and 475.205 RSMo) The undersigned states that claimant is of Street in State of and is a(corporation) (partnership) (individual) and that there is due claimant from this estate the sum of $ on account of . (describe nature of claim) An itemized statement of claim showing dates and amounts is attached hereto and incorporated herein by this reference as Exhibit A. The claimant holds security for said claim as follows: . (If none, so state; otherwise describe.) Affiant states affiant is (claimant) (agent) (attorney) (officer) for claimant and that claimant has given credit to said estate for payments and offsets to which it is entitled and that the balance claimed as above stated is justly due. The undersigned swears that the matters set forth in the foregoing pleading are true and correct according to the undersigneds best knowledge and belief and subject to penalty for making a false affidavit or declaration. Dated: Affiant: Address: Page 1 of 2 >>>> 2* Service of all notice is waived: * Consent for immediate hearing is given: * Consent is given to judgment allowing claim for $ (If signed, strike any part not agreed to.) * Strike words not applicable. Personal Representative ConservatorDate of first publication: . Cla im a llowe d on , in the amount of $ and pl aced i n Class . Judge Commissioner INSTRUCTIONS AS TO CLAIMS AGAINST ESTATE For instructions as to making claims against estate, see Sec. 473.360 RSMO, et seq. as to decedents estates and Sec. 475.205 et seq. as to conservatorship estates. Form 10140 Page 2 of 2 7/29/96