THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) MOTION FOR PRIVATE CLAIM 1. Fiduciary Name Mailing Address Fiduciary Name Mailing Address 2. 3. 4. Attorney Name Mailing Address I/We have a claim against the estate of in the amount of $ . Telephone Bar ID# , late of Telephone Telephone Describe the details of your claim against the estate, explaining why the estate owes you money. (Attach additional pages if needed) I/We do not have any knowledge of any credit or offset that should be allowed against this claim. To the best of my/our knowledge and belief, the above is a true statement of the claim against the estate. I/we ask to the court to allow this claim. I certify that on this date I provided this document(s) to the parties who have filed an appearance for this case or who are otherwise interested parties by: Hand-delivery OR US Mail OR Email (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order). Date Fiduciary Signature (must be signed in presence of notarial officer) Fiduciary Signature (must be signed in presence of notarial officer) Date State of This instrument was acknowledged before me on , County of by Fiduciary Signature of Notarial Officer / Title Date My Commission Expires Affix Seal, if any ORDER Motion for Private Claim is allowed. Motion for Private Claim is disallowed. Date NHJB-2628-P (03/25/2013) Judge American LegalNet, Inc. www.FormsWorkFlow.com