Free 3C-E-023CreditorsClaim - Hawaii

STATE OF HAWAI`I CIRCUIT COURT OF THE THIRD CIRCUIT
THE ESTATE OF

CASE NUMBER

CREDITOR'S CLAIM

P. No.

DECEASED CLAIMANT'S NAME, ADDRESS, AND TELEPHONE NO. AMOUNT OF CLAIM

PER CERTIFIED STATEMENT ATTACHED

STATE OF HAWAI`I CITY & COUNTY OF

) ) )

SS

Affiant being first duly sworn, on oath deposes and says; that affiant makes this claim in the capacity stated below; that the foregoing claim amounting to the sum indicated against the estate of the above named deceased is justly due and owing. No payments have been made which have not been credited and that there are no offsets against the claim, to the knowledge of this affiant.

AFFIANT'S NAME AND TITLE

SIGNATURE

SUBSCRIBED AND SWORN BEFORE ME THIS DATE:

NOTARY PUBLIC/CLERK

MY COMMISSION EXPIRES:

FOR COURT USE ONLY

STATE OF HAWAI`I

In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the Circuit Court Administration Office at PHONE NO. 961-7440, FAX 961-7416, or TTY 961-7525 at least ten (10) working days prior to your hearing or appointment date.
Reprographics (03/07)

CREDITOR'S CLAIM 3C-E-023

CLEAR