CLAIM AGAINST ESTATE IN THE ESTATE OF: _________________________________________________________ The Claimant certifies that there is due and owing from _____________________, the decedent, the sum of $ __________________ due by reason of ___________________________ _____________________________________________________________________________, pursuant to the attached original invoice. On behalf of the claimant, I do solemnly declare and affirm under the penalties of perjury that the information and representations made herein are true and correct to the best of my knowledge, information and belief. Dated this _______ day of __________________________, 20____. __________________________________ Name of Claimant __________________________________________ Signature of Claimant or person authorized to make verification on behalf of Claimant __________________________________________ Address __________________________________________ City, State and Zip Code STATE of _____________________ COUNTY of ____________________, to-wit: Subscribed and sworn to before me, a Notary Public in and for the County and State aforesaid, this _______ day of ________________________, 20 _____. ______________________________ Notary Public My Commission Expires: ____________________ A filing fee in the amount of $25.00 is due upon filing in this office. Your claim will not be processed if you do not submit the $25.00 fee. _________________________________________________________________________ FOR OFFICE USE ONLY Received and Docketed this ________day of ____________________, 20____ By: _________________________________________ Assistant to the Commissioner of Accounts American LegalNet, Inc. www.USCourtForms.com