Claim Form. This is a Missouri form and can be use in 21st Circuit (St. Louis County) Local Circuit Courts.
Tags: Claim, CCPR004, Missouri Local Circuit Courts, 21st Circuit (St. Louis County)
INSTRUCTIONS FOR FILING CLAIMS AGAINST AN ESTATE Information on making claims against an estate can be found in Section 473.360 RSMo for decedent’s estates and Section 475.205 RSMo for conservatorship estates. ALL CLAIMS AGAINST AN ESTATE MUST BE FILED IN DUPLICATE. IN THE PROBATE DIVISION, CIRCUIT COURT, ST. LOUIS COUNTY, MISSOURI In the Matter of ____________________________________________________________ No. ______________ Deceased, Disabled, Minor CLAIM Claimant, _________________________________, which is a (corporation) (partnership) (individual) and (type or print name) states that there is due claimant from this estate the sum of $ _______________________ based upon the ATTACHED ITEMIZED STATEMENT. Claimant holds security as follows (if none, so state; otherwise describe): The undersigned states (he) (she) is the (claimant) (agent) (attorney) (officer) for claimant and has to the best of undersigned’s knowledge and belief, 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 City State Zip Code Attorney for Claimant: ______________________________________________________________________ Name Address WAIVER OF SERVICE OF NOTICE OF CLAIM; CONSENT TO ALLOWANCE (Strike any portion not applicable) 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 CCPR004 – 11/10 American LegalNet, Inc. www.FormsWorkFlow.com