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CASE NUMBER: ESTATE OF(Name): DECEDENT FACTS SUPPORTING THE CREDITOR'S CLAIM See attachment (if space is insufficient) Amount claimed Date of item Item and supporting facts TOTAL $ PROOF OFL_J MAILIN= PERSONAL DELIVERY TO PERSONAL REPRESENTATIVE (Be sure to mail or take the original to the court clerk's office for filing) 1. I am the creditor or a person acting on behalf of the creditor. At the time of mailing or delivery I was at least 18 years of age. 2. My residence or business address is (specify): 3. 1 mailed or personally delivered a copy of this Creditor's Claim to the personal representative as follows (check either a orb beloe a.0 Mail. I am a resident of or employed in the county where the mailing occurred. (1) 1 enclosed a copy in an envelope AND (a) = deposited the sealed envelope with the United States Postal Service with the postage fully prepaid. (b) = placed theenvelopeforcollection and mailing onthe dateand atthe placeshown in Items belowfollowing our ordinary business practices. I am readily familiar with the business' practice for collecting and processing correspondence for mailing.On the same daythatcorrespondence is placed for collection and mailing,itis deposited in the ordinary course of business with the United States Postal Service in a sealed envelope with postage fully prepaid. (2)The envelope was addressed and mailed first-class as follows: (a) Name of personal representative served: (b) Address on envelope: (c) Date of mailing: (d) Place of mailing (city and state): b.0 Personal delivery. I personally delivered a copy of the claim to the personal representative as follows: (1) Name of personal representative served: (2) Address where delivered: (3) Date delivered: (4) Time delivered: 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 OF CLAIMANT) (SIGNATURE OF CLAIMANT) DE-172(Rev.Jan,ary 1,19981 CREDITOR'S CLAIM Page Two (Probate) 0