Affidavit in Lieu of Inventory - Harris County Probate Court

Estate Claim Form

NO.

IN RE: THE ESTATE OF

DECEASED IN THE PROBATE COURT

NUMBER () OF

HARRIS COUNTY, TEXAS

SWORN STATEMENT SUPPORTING CLAIM AGAINST ESTATE

TO: CLERK OF SAID COURT; and/or

TO: INDEPENDENT EXECUTOR OF SAID ESTATE

A. I, , hereafter called "AFFIANT," do solemnly swear that the foregoing and attached claim against the above numbered and styled estate, amounting to the sum of $ is a just claim, and that all legal offsets, payments and credits known to AFFIANT have been allowed, and that the sum herein claimed is justly due.

B. CLAIMANT is:

CLAIMANT's address is:

C.

1. This claim is founded on a written instrument or account, a true copy of which is attached as "EXHIBIT A," incorporated herein by reference;

or,

2. This claim is NOT founded on a written instrument or account and the facts upon which the claim is founded are as follows:

D.

1. AFFIANT is the owner and holder of the above claim and has personal knowledge of the facts herein contained; and all statements herein are within my personal knowledge and are true and correct;

or,

2. The AFFIANT is NOT the owner of said claim, but is a duly authorized officer, agent or representative, to-wit: ; and I have made diligent inquiry and examination of this claim and I believe the claim is just and that all legal offsets, payments, and credits made known to this AFFIANT have been allowed.

E. AFFIANT files this Claim in behalf of the above named CLAIMANT and prays that

same be timely approved in accordance with applicable provisions of the Texas Probate Code; and CLAIMANT requests that said claim be classified as a CLASS CLAIM pursuant to § 322, Texas Probate Code, and given preferential treatment.

[Class 1 - funeral and last sickness expenses - $15,000 limit; Class 2 - Administration and safekeeping expenses; Class 3 - secured claims, including tax liens; Class 4 - special Texas liens and taxes; Class 5 - confinement costs; Class 6 - state medical benefits; Class 7 - all other claims.]

SWORN TO and SUBSCRIBED BEFORE ME by the above named AFFIANT on this the day of , 20

Mailed by certified mail, return receipt requested

to:

CMRRR # on , 20

Filed with clerk of court on , 20

NO.

IN RE: THE ESTATE OF

DECEASED IN THE PROBATE COURT

NUMBER () OF

HARRIS COUNTY, TEXAS

EXECUTOR'S APPROVAL OR DENIAL OF CLAIM AGAINST ESTATE

TO: CLERK OF SAID COURT; and/or

TO: CLAIMANT,

Re: CLAIM for $ filed by

On , 20 , the above claim for $ was filed

with the County Clerk and/or was filed

with the (Independent Executor)(Administrator).

The CLAIM IS APPROVED IN THE TOTAL AMOUNT STATED.

The CLAIM IS REJECTED BECAUSE OF THE FOLLOWING DEFECTS IN THE CLAIM FORM OR EXHIBITS AS SUBMITTED (§ § 301, 302, 304):

The CLAIM IS TOTALLY REJECTED BECAUSE THE CLAIM IS BARRED BY TEXAS' STATUTE OF LIMITATION.

The CLAIM IS TOTALLY REJECTED BECAUSE:

The CLAIM IS PARTIALLY APPROVED IN THE FOLLOWING AMOUNT

ONLY: $ ; AND, REJECTED AS TO THE BALANCE.

REASON:

The CLAIM IS CLASSIFIED AS A CLASS CLAIM IN THE AMOUNT OF $ AND CLASS CLAIM FOR THE BALANCE.

A copy of this approval/rejection action has been delivered to CLAIMANT as below indicated.

Dated this day of 20

CMRRR# to Date:

Personally served on Date: