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Fill and Sign the Claim of the Undersigned is Hereby Made Against This Estate Itemized as Follows Form

Fill and Sign the Claim of the Undersigned is Hereby Made Against This Estate Itemized as Follows Form

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STATE OF NEBRASKA STATEMENT OF CLAIM Case No. IN THE MATTER OF THE ESTATE OF STATEMEN T OF CLAIM Clai m No. , Deceased. TO THE CLERK OF THE COURT: Claim of the undersigned is hereby made against this estate, itemized as follows: Des cription of Claim Due Date, If Not Yet Due Amount See attached bill or other documentation. Total Claim: This claim is: Contingent Unliquidated and the nature of the uncertainty is: Secured, and a description of the security is: Unsecured. PRESENT THIS CLAIM TO THE COURT Date Signature Claimant or Authorized Party Name Bar Number and Firm Name (attorneys only) Claimant or Authorized Party Street Address/P.O. Box Claimant or Authorized Party City/State/ZIP Code Claimant or Authorized Party Phone/Fax Claimant or Authorized Party E-mail Address CC 15:2 REV 04/2018 Neb. Rev. Stat. § 30-2486 Page 1 of 1 Statement of Claim CC 15:2 Rev 0 4/2018 IN THE COUNTY COURT OF __________________ COUNTY, NEBRASKA

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