1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 CC24 Name (Attorneys Include Bar No. & Firm Name) Address City/State/Zip Telephone In Proper Person OR Attorney for DISTRICT COURT CLARK COUNTY, NEVADA In the Matter of the Estate of Estate Name _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Deceased. Case No. CASE NO._____________ Dept. No. DEPT. NO._____________ CREDITOR'S CLAIM The undersigned, a creditor of the above-named Decedent, hereby presents the following claim: (Describe claim and attach copies of supporting documentation and, if interest is due, state separately the amount of interest and the rate of interest.) $_________ Amount ______________________________________________________________________ Describe Claim ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ... CreditorsClaim.doc/3/15/2005 American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 STATE OF STATE COUNTY OF COUNTY ) ) ) ss: , being duly sworn, states: that he/she is the Name creditor the duly authorized agent of the creditor named above, who has filed the foregoing claim against the Estate of the above-named Decedent; that the amount of the claim is justly due or is a just demand and will become due on the date set forth above; that all payments have been credited; that there are no offsets known to affiant which have been credited; and (complete if applicable) affiant rather than the creditor has filed this claim for the reason that:______________________________________ State Reason ____________________________________________________________________. I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct. EXECUTED this Day day of Month , 20 Yr. . _____________________________ ____________________________ Name ____________________________ Address ____________________________ City, State & ZIP _____________________________ Telephone The foregoing claim filed in the Estate of the above-named Decedent is: Rejected Allowed in the sum of $ Amount . _____________________________ Personal Representative Date NOTE TO CREDITOR: If your claim is rejected, you have 60 days in which to file suit or the claim is forever barred. NRS 147.130. 2 CreditorsClaim.doc3/15/2005 American LegalNet, Inc. www.FormsWorkFlow.com