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Superior Court of the District of Columbia PROBATE DIVISION CLAIM AGAINST DECEDENT S ESTATE The creditor named below certifies that there is owing by deceased Admin. No. in accordance with the statement of account attached hereto as a part hereof the sum of together with interest at the rate of from until paid and that the aforesaid account is correct as stated and is unpaid. On behalf of the creditor named below I do solemnly declare and affirm under penalty of law that the contents of the foregoing document are true and correct to the best of my knowledge and belief. Decedent died on and was a resident of Signature of Creditor or person authorized to make verification on behalf of creditor Name of Creditor Please print Address INSTRUCTIONS In addition to completing all pertinent blank spaces on the form the claimant shall use these lines to state 1. The due date if the claim is not yet due 2. The nature of the contingency if the claim is contingent 3. The description of the security if the claim is secured 4. Nature of claim* All claims presented to the Register of Wills must be accompanied by check or money order in the amount of 5. 00 payable to the Register of Wills D*C* I hereby certify that I have delivered or mailed return FOR REGISTER OF WILLS USE ONLY receipt requested a copy hereof to representative or attorney this Date Filed personal Claims Docket Book Page day of Claimant Fwm FD 25 -UN/ Jun By Deputy Register of Wills. The due date if the claim is not yet due 2. The nature of the contingency if the claim is contingent 3. The description of the security if the claim is secured 4. Nature of claim* All claims presented to the Register of Wills must be accompanied by check or money order in the amount of 5. The description of the security if the claim is secured 4. Nature of claim* All claims presented to the Register of Wills must be accompanied by check or money order in the amount of 5. 00 payable to the Register of Wills D*C* I hereby certify that I have delivered or mailed return FOR REGISTER OF WILLS USE ONLY receipt requested a copy hereof to representative or attorney this Date Filed personal Claims Docket Book Page day of Claimant Fwm FD 25 -UN/ Jun By Deputy Register of Wills. The due date if the claim is not yet due 2. The nature of the contingency if the claim is contingent 3. The description of the security if the claim is secured 4. Nature of claim* All claims presented to the Register of Wills must be accompanied by check or money order in the amount of 5. 00 payable to the Register of Wills D*C* I hereby certify that I have delivered or mailed return FOR REGISTER OF WILLS USE ONLY receipt requested a copy hereof to representative or attorney this Date Filed personal Claims Docket Book Page day of Claimant Fwm FD 25 -UN/ Jun By Deputy Register of Wills.

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