STATE OF NEBRASKA STATEMENT OF CLAIM CC 15:2 REV 01/2015 Neb. Rev. Stat. §30-2486 IN THE COUNTY COURT OF _____________________________COUNTY, NEBRASKA IN THE MATTER OF THE ESTATE OF CASE NUMBER , Deceased. STATEMENT OF CLAIM Claim No. TO THE CLERK OF THE COURT: Claimant of the undersigned is hereby made against this estate, itemized as follows: Description of Claim Due Date, If Not Yet Due Amount See attached bill or other documentation. Total Claim: This claim is: Contingent Unliquidated and the nature of the uncertainty is: Secured, and a description of the security is: Unsecured. PRESENT THIS CLAIM TO THE COURT Date Signature Claimant or Authorized Party Name Bar Number and Firm Name (attorneys only) Claimant or Authorized Party Street Address/P.O. Box Claimant or Authorized Party City/State/ZIP Code Claimant or Authorized Party Phone/Fax Claimant or Authorized Party E-mail Address Page 1 of 1 Statement of Claim CC 15:2 Rev 01/2015 American LegalNet, Inc. www.FormsWorkFlow.com