**MUST BE SUBMITTED ON PINK PAPER CIRCUIT COURT OF CLAY COUNTY, MISSOURI PROBATE DIVISION Case# , *Deceased/Disabled/Minor___. MATTER OF CLAIM AGAINST ESTATE The applicant herein states that there is due to: (Name) from the estate of account of (describe nature of claim) (Address) , *Deceased/Disabled/Minor, the sum of on An itemized statement of such claim showing dates and amounts is attached hereto along with a copy of all written documents concerning the claim. The claimant holds security for the claim as follows: . Applicant states that to the best of *his/her knowledge and belief credit has been given to such estate for all payments and offsets to which it is entitled and that the balance claimed as above stated is justly due. THE STATEMENTS AND REPRESENTATION IN THIS DOCUMENT ARE MADE UNDER OATH AND ARE TRUE AND CORRECT TO MY BEST KNOWLEDGE AND BELIEF. I UNDERSTAND THEY ARE MADE SUBJECT TO THE PENALTIES OF MAKE A FALSE AFFIDAVIT OR DECLARATION. Date Signature of Applicant I certify that a copy of this claim was served on the *Personal Representative/Conservator of the estate by mailing and delivering it to: Date Signature of Applicant Service of claim is acknowledged. Immediate hearing is requested. Consent is given to judgment in the amount of $ If signed, strike any part not agreed to. . Date *Personal Representative/Conservator The above claim is hereby allowed this ____________ day of ______________________________, 20_____, in the . amount of $ JUDGE Clerk I hereby certify that I mailed a copy of the preceding claim to the Attorney/Conservator for this case on . JOYCE GRAY, CLERK , Deputy By Form 221 Revised 10/1/2010 Page 1 of 1 *Strike if inapplicable American LegalNet, Inc. www.FormsWorkFlow.com