Nebraska State Court Form CC 15:3 Revised 05/15 RELEASE OF CLAIM IN THE COUNTY COURT OF ________________COUNTY, NEBRASKA IN THE MATTER OF THE ESTATE OF Case #____________________ Deceased RELEASE OF CLAIM The undersigned Claimant acknowledges delivery and receipt on , 20 of the following described payment which is the full amount of the claim to which the undersigned Claimant is entitled, to wit: Description of Claim: Amount: The undersigned Claimant releases and forever discharges the Personal Representative of the Estate from all claims and rights whatsoever which the undersigned may have in this Estate with respect to such claim. Date Signature Claimant Name Bar Number and Firm Name (attorneys only) Street Address/P.O. Box City/State/ZIP Code Phone E-mail Address Witness: Page 1 of 1 Release of Claim CC 15:3 Rev. 05/15 County Forms Committee American LegalNet, Inc. www.FormsWorkFlow.com