IN THE PROBATE DIVISION, CIRCUIT COURT, ST. LOUIS COUNTY, MISSOURI In the Matter of ___________________________________________________________ No. ________________ Deceased, Disabled, Minor CLAIM Claimant, _________________________________________________________________________ , makes claim for (type or print name) $ __________________________ based upon the ATTACHED ITEMIZED STATEMENT. Claimant holds security as follows: To the best of undersigned’s knowledge and belief, claimant has given credit to all payments on and offsets against the amount claimed, the balance claimed is justly due, the allegations herein are made under oath or affirmation, and the representations are true and correct to the best of undersigned’s knowledge and belief subject to the penalties of making a false affidavit or declaration. Date: _____________________________ ____________________________________________________________________ Signature of Claimant or Person Signing for Claimant ____________________________________________________________________ Name of Claimant or Person Signing for Claimant (printed or typed) ____________________________________________________________________ Title of Person Signing for Claimant (printed or typed) Address of Claimant: ________________________________________________________________________________ No. and Street Attorney for Claimant: City State Zip Code ________________________________________________________________________________ Name Address WAIVER OF SERVICE OF NOTICE OF CLAIM; CONSENT TO ALLOWANCE (Delete inapplicable part) Undersigned waives service of notice of the above claim and consents to its allowance in the amount of $ _____________________ Date: _____________________________ _______________________________________________ _______________________________________________ Signature of Attorney for Personal Representative or Conservator Signature of Personal Representative or Conservator ORDER ALLOWING CLAIM Date: _____________________________ The court ALLOWS the claim of ____________________________________________________________________________ for $ __________________________ as a(n) (unsecured) (secured) claim, the security, if a secured claim, being: _______________________________________________ JUDGE/COMMISSIONER/DEPUTY COMMISSIONER JOAN M. GILMER, CIRCUIT CLERK 3380/A (8/00) By: ____________________________________________ Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com