IN THE PROBATE DIVISION, CIRCUIT COURT, ST. LOUIS COUNTY, MISSOURI
In the Matter of
___________________________________________________________ No. ________________
Deceased, Disabled, Minor
CLAIM
Claimant, _________________________________________________________________________ , makes claim for
(type or print name)
$ __________________________ based upon the ATTACHED ITEMIZED STATEMENT. Claimant holds security as follows:
To the best of undersigned’s knowledge and belief, claimant has given credit to all payments on and offsets against the amount
claimed, the balance claimed is justly due, the allegations herein are made under oath or affirmation, and the representations are true
and correct to the best of undersigned’s knowledge and belief subject to the penalties of making a false affidavit or declaration.
Date: _____________________________
____________________________________________________________________
Signature of Claimant or Person Signing for Claimant
____________________________________________________________________
Name of Claimant or Person Signing for Claimant (printed or typed)
____________________________________________________________________
Title of Person Signing for Claimant (printed or typed)
Address of Claimant: ________________________________________________________________________________
No. and Street City State Zip Code
Attorney for Claimant: ________________________________________________________________________________
Name Address
WAIVER OF SERVICE OF NOTICE OF CLAIM; CONSENT TO ALLOWANCE
(Delete inapplicable part)
Undersigned waives service of notice of the above claim and consents to its allowance in the amount of $ _____________________
Date: _____________________________
_______________________________________________ _______________________________________________
Signature of Attorney for Personal Signature of Personal Representative
Representative or Conservator or Conservator
ORDER ALLOWING CLAIM
Date: _____________________________
The court ALLOWS the claim of ____________________________________________________________________________
for $ __________________________ as a(n) (unsecured) (secured) claim, the security, if a secured claim, being:
_______________________________________________
JUDGE/COMMISSIONER/DEPUTY COMMISSIONER
ROBERT C. WEIS, CLERK
3380/A (8/00) By: ____________________________________________
Deputy Clerk