Revised 09/2018 1 of 3 473.090.1 (2) RSMo APPLICATION FOR REFUSALS Fees of $ 103.50 due Add all parties: applicant and decedent Need c opy of death certificate with decedent222s SS# & address Need SS# and birthdate of Applicant Need documentation in support of asset(s) trying to collect (ie car title, bank statement) Creditor222s Refusal should contain the following: Need d ate of death of decedent Need domicile address of decedent Need a statement that there is no spouse or unmarried minor children Need the amount owed the creditor Nature of the debt (ie funeral) Need statement that the entire estate does not exceed $15,000.00 Need description and value of the property attempting to collect Need a statement that the applicant will pay the debts of decedent so far as the assets will permit, in the order of preference established by law, and will distribute the balance of the estate, if any, to the persons entitled thereto under the law If assets at tempting to collect are larger than creditor is owed, need a surety bond for the difference if difference is over $2,000 If difference is under $2,000, need a personal bond Need itemized funeral bill stamped paid or indicating a zero balance Need receipt for payment to funeral home (ie cancelled check, credit card statement, assignment of benefit form if beneficiary of life insurance that paid for funeral) Need to be signed and dated by applicant under oath and affirmation or notarized American LegalNet, Inc. www.FormsWorkFlow.com Revised 09/2018 2 of 3 473.090.1 (2) RSMo TWENTY SECOND JUDICIAL CIRCUIT Probate Division Case Number: In the Estate of , Deceased. (Date File Stamp) Application of Creditor for Refusal of Letters The applicant states that the decedent died on residing at , leaving no surviving spouse or unmarried minor children; that after giving credit for all payments and offsets to which the estate is entitled there is now due and owing applicant, as a creditor of decedent, the sum of $ , for (state nature of debt): . The entire estate of decedent does not exceed the value of $15,000.00 and consists solely of personal property described and of a value as follows: Description of Property Value See Appendix A. Total $ Applicant further states that if this application is granted, applicant will pay the debts of decedent so far as the assets thereof will permit, in the order of preference established by law, and will distribute the balance of said estate, if any, to the persons entitled thereto under the law. Wherefore, applicant prays the court order no letters be granted on said estate unless on the application of creditors or other parties interested the existence of other or further property is shown. The applicant swears that the matters set forth above are true and correct to the best knowledge and belief of the applicant, subject to the penalties of making a false affidavit or declaration. Date: Signature of Attorney for Applicant Signature of Applicant (Name/Bar Number/Address/Telephone/Fax/E-Mail) (Name/Address/Telephone) American LegalNet, Inc. www.FormsWorkFlow.com Revised 09/2018 3 of 3 473.090.1 (2) RSMo Appendix A Decedent: Case Number: Description of Property Value Personal Property TOTAL: American LegalNet, Inc. www.FormsWorkFlow.com