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In the Matter of the Estate of: WRITTEN STATEMENT OF CLAIM , (Full Name) Decedent

1. I, state my name is: ______________________________________________________ and I have a valid claim against this estate. 2. My address and telephone number are: _______________________________________ _______________________________________________________________________. 3. The Estate is or will become indebted to me in the amount of $_____________________. 4. The nature of the claim is: _________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________. 5. The claim arose prior to the death of the Decedent on or about____________________ after the death of the Decedent, on or about ____________________. or unsecured, or 6. The claim is secured by: ______________________________________________ _______________________________________________________________________. 7. The claim is is not based on a contract which makes a provision for interest. 8. The claim was or will be due and payable on __________________________________. 9. If the claim is contingent or unliquidated, the nature of the uncertainty is as follows: ___ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________. 10. Under penalties for perjury, I declare or affirm that I have read this document and I know or believe its representations are true and complete.

Dated:
Signature

Name: Street Address: City/State/Zip:

PRO402

State

ENG

Rev 9/06

www.mncourts.gov/forms

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