Free Statement of Claim, CC 15:2 - Nebraska

STATE OF NEBRASKA FORM NO. CC 15:2

CASE NUMBER

STATEMENT OF CLAIM

IN THE COUNTY COURT OF _____________________________COUNTY, NEBRASKA IN THE MATTER OF THE ESTATE OF

STATEMENT OF CLAIM
Claim No. , Deceased.
TO THE CLERK OF THE COURT: Claimant of the undersigned is hereby made against this estate, itemized as follows: Description 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

Signature of Claimant or Authorized Party

Name of Claimant or Authorized Party

Address of Claimant or Authorized Party

Telephone Number of Claimant or Authorized Party

Fax Number of Claimant or Authorized Party