SURROGATE'S COURT OF THE STATE OF NEW YORK - COUNTY ____________________________________ In the Matter of the Estate of VERIF IED CL AIM FILE # ___________________________ Deceased ____________________________________ To a fiduciary to whom Letters were issued for the above named estate: Fiduciary Nam e:____________________________________________________________________________________ Fiduciary Com plete Address:_______________________________________State:______________Zip:_____________ 1. The undersigned is the owner and holder of a claim against the above named estate. 2. The claim is in the am ount of $ . 3. The facts upon which the claim is based are as follows:_________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 4. A copy of an invoice, statement or voucher [ ] is / [ ] is not attached. 5. No payments have been made upon the amount claimed except as follows:__________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 6. No offsets against this claim exist, except as follows:_____________________________________________________ _________________________________________________________________________________________________ 7. The claimant holds no security, except as follows:_______________________________________________________ _________________________________________________________________________________________________ _______________________________________ Corporate Claimant _______________________________________ Claimant _______________________________________ Corporate Officer _______________________________________ Print Name VERIFICATION State of New York } County of } ss: [Individual] I am the claimant of the foregoing claim; the claim is true to my own knowledge, except as to matters stated upon information and belief and as to those matters I believe them to be true. [Corporation] I am the of the corporation named as claimant; I have read the foregoing claim and know the contents thereof; the same is true of my own knowledge, except as to the matters therein stated to be alleged upon information and belief, and as to those matters I believe it to be true; the reason why this verification is made by me and not by claimant is that the claimant is a corporation; the source of my information and the greounds of my belief as to all matters in claim not stated upon my own knowledge are investigations which I have made or caused to be made concerning the subject matter of this claim and information acquired by me in the course of my duties as an officer of the corporation. Subscribed and sworn to before me on this Day of , Address: ___________________________ Notary Public _______________________________ Claimant _______________________________ _______________________________ My commission expires: Attorney for Claimant Name Addres s: Tel. No. [A copy of the claim must be given to the fiduciary in person or by certified mail, return receipt requested. See SCPA §1803(2). You may use the attached form for the affidavit of mailing and attach the return receipt (green card).] NYSBA's Surrogate's Court Form, Verified Claim American LegalNet, Inc. www.FormsWorkflow.com SURROG ATE'S COURT OF THE STATE OF NEW YORK - COUNTY _____________________________________ In the Matter of the Estate of AFFIDAVIT OF MAILING OF VERIFIED CLAIM Deceased ____________________________________ _____________________________________ STATE OF NEW YORK COUNTY OF FILE #________________________ } } ss.: I,___________________________________________________, being duly sworn, deposes and says: Deponent is over the age of eighteen years and on ______________________________________ deponent mailed a copy of the Verified Claim, contained in a securely closed postpaid wrapper, directed to each of the persons named in the within claim at the addresses set forth therein, by depositing same in a letter box or other official depository under the exclusive care and custody of the United States Post Office, located at:__________________________________________________________. The attached is a Verified Claim (by a creditor pursuant to SCPA §1803 (2)), (a copy of which is attached). Sworn to before me on ______________________, 20___ ___________________________________ Affiant _____________________________ Notary Public ___________________________________ Print Name My commission expires: Attorney for Person Giving Notice Name:_____________________________________________________ Address:___________________________________________________ Tel. No.:____________________________________________________ (Attach green card here) [NOTE: A COPY OF THE CLAIM REFERRED TO ABOVE MUST BE SERVED ON THE FIDUCIARY OF THE ESTATE; THE CLAIM WILL NOT BE ACCEPTED BY THE COURT WITHOUT AN AFFIDAVIT OF SERVICE (ATTACH GREEN CARD)] NYSBA's Surrogate's Court Form, Verified Claim -2- American LegalNet, Inc. www.FormsWorkflow.com