Certified claims (original plus 2 copies) must be filed with the Hamilton County CLERK & MASTER, 625 Georgia Ave, Room 300 Courthouse, Chattanooga, TN 37402, within four months from the first publication date of notice to creditors. When any claim is due on an open account, an itemized statement of the account shall be filed; when evidenced by a written instrument, such instrument, or a copy attested by the CLERK & MASTER as a true copy of the same, shall be filed; and when due by judgment or decree, a copy certified by the Clerk of the Court rendering same shall be filed. Every claim must be verified by the affidavit of the creditor. The $11.00 claim fee authorized by T.C.A. § 8-21-401(c)(1)(A) shall be paid to the CLERK & MASTER by the claimant at the time such claim is filed. All claims filed more than 12 months from the decedent's date of death will be returned unfiled. Acts 2007, Ch. 8, Sec. 1, eff. March 28, 2007; T.C.A. § 30-2-307(d). IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE IN THE MATTER OF THE ESTATE OF VERIFIED CLAIM AGAINST ESTATE PART 2 FILE N0. PROBATE DIVISION PERSONAL REPRESENTATIVE(S) DECEASED CREDITOR ADDRESS Date Items & Nature of Claim Amount Credits Balance Due TOTAL DUE STATE OF } COUNTY OF } The undersigned makes oath this claim is a correct, just, and valid obligation of this estate, that neither the undersigned nor any other person on behalf of the undersigned has received payment therefor, in whole or in part, except as is above credited, and no security has been received therefore, except as above stated. This __________ day of ______________________, 20___. Sworn to and subscribed before me this ____ day of __________, 20___. My commission expires:______________ __________________________________________ CREDITOR SIGNATURE __________________________________________ Notary Public ______________________________________ {Attorney for Creditor, if any} {BPR N0.} ______________________________________ Address ______________________________________ {Tel. N0.} {Fax N0.} ______________________________________ Verified Claim Against Estate Form 087P, Rev. 2008.03.12 American LegalNet, Inc. www.FormsWorkFlow.com