IN THE PROBATE DIVISION, CIRCUIT COURT, ST. LOUIS COUNTY, MISSOURI In the Matter of
___________________________________________________________
Deceased, Disabled, Minor
No. ________________
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: Attorney for Claimant:
________________________________________________________________________________
No. and Street City State Zip Code
________________________________________________________________________________
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 Representative or Conservator
_______________________________________________
Signature of Personal Representative 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