MISSOURI CIRCUIT COURT, TWENTY-SECOND JUDICIAL CIRCUIT PROBATE DIVISION, CITY OF ST. LOUIS In the estate of No. Deceased/Disabled C L A I M A G A I N S T E S T A T E Claimant, , makes a claim against this estate for $ , in accordance with the ATTACHED ITEMIZED STATEMENT describing the nature and amount of the claim. Claimant holds security as follows: The undersigned, having knowledge of the facts, states that to the best of payments and offsets to which it is entitled, the balance claimed is justly due, the allegations herein are made under oath or affirmation, and the representations are true of making a false affidavit or declaration. Signed this day of , . Full Firm Name Signature of Individual Claimant By: Name of Individual Claimant (Typed) Title: Street Address City State Zip Code MBE# Address City State Zip Code Attorney Telephone/Fax No. E-Mail WAIVER OF SERVICE OF NOTICE OF CLAIM; CONSENT TO ALLOWANCE (Check applicable statements) ( ) Service of notice of the above claim is hereby waived. ( ) Consent to allow the claim in the amount of $ is hereby given. Signed this day of , 20. Signature of Attorney Signature of Personal Rep./Conservator American LegalNet, Inc. www.FormsWorkFlow.com Pursuant to Missouri Supreme Court Rules governing eFiling, Notice of the foregoing Claim against the Estate has been provided to the attorneys of record by an eService email. American LegalNet, Inc. www.FormsWorkFlow.com