Free pc579.pmd - Michigan

Approved, SCAO

JIS CODE: SPC

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. STATEMENT AND PROOF OF CLAIM

Estate of

I,

Creditor's name

of

Address

submit the following claim against the estate for the sum set forth.*

DESCRIPTION OF CLAIM

AMOUNT

There is now due on the claim, above all legal setoffs, the sum of:

0.00

Notice to interested persons: This is a claim by a personal representative for an obligation that arose before the death of the decedent. A hearing will be held to determine whether to allow the claim. You may object to the claim before or at the hearing. I declare under penalties of perjury that this statement and proof of claim has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Attorney signature Name (type or print) Address City, state, zip Telephone no. Bar no. Date Claimant signature Address City, state, zip Telephone no.

* 1. Describe nature of claim or attach a statement. Attach copy of receipt or other evidence of payment if submitted by assignee. 2. Claims must be presented either personally or by mail to the fiduciary on or before the last day for presentment of claims. This claim may also be filed with the probate court (see reverse side for proof of service). PLEASE SEE OTHER SIDE
Do not write below this line - For court use only

PC 579 (9/07)

STATEMENT AND PROOF OF CLAIM

MCL 700.3804, MCL 700.5429, MCL 700.7505, MCR 5.307(C)

PROOF OF SERVICE I served upon
Name

, by
Date State method and address of service

fiduciary, a copy of this statement and proof of claim on

.

I declare under the penalties of perjury that this proof of service has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date Signature

ACKNOWLEDGMENT OF SERVICE Service of the attached statement and proof of claim is acknowledged.
Date Signature