Creditor Claim Form

CREDITOR'S CLAIM AGAINST ESTATE

COURT INFORMATION

State of: [________________________________]

County of: [________________________________]

Court: [☐ Probate Court ☐ Surrogate's Court ☐ Superior Court ☐ Circuit Court]

Case Number: [________________________________]

IN THE MATTER OF THE ESTATE OF:

Decedent's Full Legal Name: [________________________________]

Also Known As: [________________________________]

DECEASED

I. CLAIMANT INFORMATION

Full Legal Name of Claimant:

☐ Individual: [________________________________]

☐ Business/Corporation: [________________________________]
State of Organization: [________________________________]

Claimant's Mailing Address:
Street: [________________________________]
City: [________________] State: [____] Zip: [________]

Telephone: [(___)___-____]

Fax: [(___)___-____]

Email: [________________________________]

Contact Person (if entity): [________________________________]

II. CLAIMANT'S REPRESENTATIVE (if applicable)

Attorney/Authorized Representative:
Name: [________________________________]
Bar Number: [________________________________]
Firm: [________________________________]
Address: [________________________________]
Telephone: [(___)___-____]
Email: [________________________________]

III. CLAIM INFORMATION

A. Amount of Claim

Total Amount Claimed: $[________________________________]

Itemized as follows:

B. Nature and Basis of Claim

Type of Claim:

☐ Contract/Agreement
☐ Promissory Note/Loan
☐ Credit Card/Line of Credit
☐ Medical/Healthcare Services
☐ Goods Sold and Delivered
☐ Services Rendered
☐ Mortgage/Deed of Trust
☐ Lease/Rental Agreement
☐ Taxes Owed
☐ Court Judgment
☐ Personal Injury/Tort
☐ Other: [________________________________]

Detailed Description of Claim:

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Date Claim Arose: [__/__/____]

Date Debt Became Due: [__/__/____]

C. Claim Status

Is the claim currently due?
☐ Yes - became due on [__/__/____]
☐ No - will become due on [__/__/____]

Is the claim contingent?
☐ No
☐ Yes - Contingency: [________________________________]

Is the claim unliquidated (amount uncertain)?
☐ No - Amount is fixed and certain
☐ Yes - Estimated amount: $[____________]
Basis for estimate: [________________________________]

Is the claim disputed?
☐ No
☐ Yes - Describe dispute: [________________________________]

D. Security for Claim

Is the claim secured?

☐ No - This is an unsecured claim

☐ Yes - This claim is secured by:

Type of Security:
☐ Real property mortgage/deed of trust
☐ Security interest in personal property
☐ Vehicle lien
☐ Judgment lien
☐ Other: [________________________________]

Description of Collateral:
[________________________________]
[________________________________]

Location of Collateral:
[________________________________]

Recording Information (if applicable):
Document Type: [________________________________]
Recording Date: [__/__/____]
Instrument/Document Number: [________________________________]
Book/Page: [________________________________]
County: [________________________________]

Estimated Value of Security: $[____________]

Amount of Claim in Excess of Security Value (unsecured portion): $[____________]

E. Priority of Claim

Claimant asserts this claim has the following priority:

☐ Costs of administration
☐ Funeral expenses
☐ Federal priority debt (specify): [________________________________]
☐ Medical expenses of last illness
☐ State priority debt (specify): [________________________________]
☐ General unsecured claim
☐ Other: [________________________________]

IV. SUPPORTING DOCUMENTATION

The following documents are attached in support of this claim:

☐ Original or copy of contract/agreement
☐ Promissory note
☐ Account statements
☐ Invoices
☐ Itemized billing records
☐ Proof of delivery of goods/services
☐ Court judgment
☐ Security agreement/UCC filing
☐ Mortgage/deed of trust
☐ Correspondence with decedent
☐ Payment history
☐ Other: [________________________________]

Number of pages attached: [____]

V. TIMELY FILING DECLARATION

Date of Decedent's Death: [__/__/____]

Date Letters [Testamentary/of Administration] Issued: [__/__/____]

Date of First Publication of Notice to Creditors: [__/__/____]

Statutory Deadline for Filing Claims: [__/__/____]

Date of This Claim: [__/__/____]

☐ This claim is timely filed within the statutory period

☐ This claim is filed after the statutory period because:
[________________________________]

VI. PREVIOUS COLLECTION EFFORTS

Has demand been made on the estate for this claim?
☐ No
☐ Yes - Date of demand: [__/__/____]
Response received: ☐ No ☐ Yes - [________________________________]

Was any payment received from the estate?
☐ No
☐ Yes - Amount: $[____________] Date: [__/__/____]

Is there any pending litigation regarding this claim?
☐ No
☐ Yes - Court: [________________________________]
Case Number: [________________________________]
Status: [________________________________]

VII. VERIFICATION

I, [CLAIMANT NAME or AUTHORIZED REPRESENTATIVE], declare under penalty of perjury under the laws of the State of [STATE] that:

1. I am the claimant or authorized to act on behalf of the claimant in this matter.

2. I have read this Creditor's Claim and know its contents.

3. The claim set forth above is a just claim against the Estate.

4. The amount stated is justly due, or will become due, and no payments have been made thereon which are not credited.

5. There are no offsets, counterclaims, or credits except as stated.

6. The supporting documents attached are true and correct copies.

7. This claim is being filed within the time allowed by law, or if late, the circumstances justifying late filing are accurately stated.

Executed on [DATE] at [CITY], [STATE].

_________________________________
Signature of Claimant or Authorized Representative

_________________________________
Printed Name

_________________________________
Title (if representative)

VIII. NOTARIZATION (if required by jurisdiction)

STATE OF [________________________________]
COUNTY OF [________________________________]

On [DATE], before me, [NOTARY NAME], a Notary Public, personally appeared [CLAIMANT/REPRESENTATIVE NAME], who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged that they executed the same.

_________________________________
Notary Public Signature

My Commission Expires: [____________]

[NOTARY SEAL]

FILING INSTRUCTIONS

Where to File:

1. File Original with Court:

[Court Name]
[Address]
[City, State ZIP]

Filing Fee: $[________] (if applicable)

2. Serve Copy on Personal Representative:

[Personal Representative Name]
[Address]
[City, State ZIP]

OR Attorney for Personal Representative:

[Attorney Name]
[Address]
[City, State ZIP]

Proof of Service

I served a copy of this Creditor's Claim on the Personal Representative (or attorney) by:

☐ Personal delivery on [__/__/____]
☐ First class mail on [__/__/____]
☐ Certified mail, return receipt requested on [__/__/____]

_________________________________
Signature

FOR PERSONAL REPRESENTATIVE USE ONLY

Date Claim Received: [__/__/____]

Claim Number Assigned: [________________________________]

Action Taken:

☐ Claim ALLOWED in full: $[____________]

☐ Claim ALLOWED in part: $[____________]
Reason for partial allowance: [________________________________]

☐ Claim REJECTED
Reason for rejection: [________________________________]

☐ Claim requires further investigation

Date of Action: [__/__/____]

Signature of Personal Representative: _________________________________

FOR COURT USE ONLY

Date Filed: [__/__/____]

Claim Number: [________________________________]

Filed by: [________________________________]

Deputy Clerk: [________________________________]

END OF CREDITOR'S CLAIM FORM