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0 , r DE-172 ATTORNEY OR PAR`rY WITHOUT ATTORNEY(Name,state bar number,and address): TELEPHONE AND FAX NOS.: FOR COURT USE ONLY ATTORNEY FOR(Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: ESTATE OF(Name): DECEDENT CREDITOR'S CLAIM CASE NUMBER: You mustf ilethis clalmwith the court clerk atthe court address above beforethe LATER of Wfour months afterthe date letters (authority to act for the estate)were first issued to the personal representative,or(b)sixty days after the date the Notice of Administration was given to the creditor,if notice was given as provided in Probate Code section 9051,You mustalso mail or deliver a copy of this claim to the personal representative and his or her attorney. A proof of service is on the reverse. WARNING:Yourclaimwill in mostinstances be invalid ifyou donotproperlycompletethisform,file itontimewiththecou rt,and mail or deliver a copy to the personal representative and his or her attorney. 1. Total amount of the claim: $ 2. Claimant(name): a. an individual b. 0 an individual or entity doing business under the fictitious name of(specify): c. 0 a partnership. The person signing has authority to sign on behalf of the partnership. J. a corporation. The person signing has authority to sign on behalf of the corporation. e. other (specify): 3. Address of claimant (specify): 4. Claimant is= the creditor= a person acting on behalf of creditor (state reason): 5. = Claimant is 0 the personal representativC] the attorney for the personal representative. 6. lam authorized to make this claim which isJ'uusst and due or m��a`LL,become due.All payments on or offsets to the claim have been credited. Facts supporting the claim ari}_I on reverse LJ attached. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: TYPE OR PRINT NAME AND TITLE) (SIGNATURE OF CLAIMANT) INSTRUCTIONS TO CLAIMANT A. 0nthereverse,itemize the claim and showthedatetheservicewasrendered orthedebt Incurred.Describethe item orservicein detail,and indicatetheamountclaimedforeachitem.Do not!ncludeclebts in cu rred afterthe date of death,exceptfu neral claims. B. If the claim is not due or contingent, or the amount is not yet ascertainable, state the facts supporting the claim. C. Ifth ecl aimissecu red byan oteorotherwritte ni In stru ment,theori 91 naloracopymu stbeattach ed(statewhyoriginalisuna vailable.) If secured by mortgage,deed oftrust,orotherlien on propertythatisofrecord,it Issufficienttodes cribethesecurityand referto the date or volume and page, and county where recorded. (See Prob. Code, § 9152.) D. Mail or take this original claim to the court clerk's office for filing. If mailed, use certified mail,with return receipt requested. E. Mail or deliver a copy to the personal representative and his or her attorney. Complete the Proof of Mailing or Personal Delivery o the reverse. F. The personal representative or his or her attorney will notify you when your claim is allowed or rejected. G. Claims againstth e estate byth e personal representative and the attorneyfo rthe personal representative must befi led within the claim period allowed in Probate Code section 9100. See the notice box above. (Continued on reverse) ,,11 Form Approved by the CREDITOR'S CLAIM {�-'`�r�ai Probate Code,§§9000 et seq.,9153 Judicial C.mmAI of Callfornla SC (r15' DE-172 IRev.January 1,19981 (Probate) Mandatory Use ll/1/20001 LIS