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Here is the text we could read:

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):

TELEPHONE AND FAX NOS.:

DE-172

FOR COURT USE ONLY

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

ESTATE OF (Name):

CREDITOR'S CLAIM

DECEDENT

CASE NUMBER:

You must file this claim with the court clerk at the court address above before the LATER of (a) four months after the date letters
(authority to act for the estate) were first issued to the personal representative, or (b) sixty days after the date the Notice of
Administration was given to the creditor, if notice was given as provided in Probate Code section 9051. You must also mail or deliver a
copy of this claim to the personal representative and his or her attorney. A proof of service is on the reverse.
WARNING: Your claim will in most instances be invalid if you do not properly complete this form, file it on time with the court, and mail
or deliver a copy to the personal representative and his or her attorney.
1. Total amount of the claim: $
2.

Claimant (name):
a.
b.

an individual
an individual or entity doing business under the fictitious name of
(specify):

c.
d.
e.

a partnership. The person signing has authority to sign on behalf of the partnership.
a corporation. The person signing has authority to sign on behalf of the corporation.
other
3. Address of claimant (specify):

(specify):

(state reason):
Claimant is

a person acting on behalf of creditor

the creditor

5.
6.

B.
C.

D.
E.

F.
G.

Claimant is

the personal representative

the attorney for the personal representative.

I am authorized to make this claim which is just and due or may become due. All payments on or offsets to the claim have been
credited. Facts supporting the claim are

on reverse

attached.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:

(TYPE OR PRINT NAME AND TITLE)

(SIGNATURE OF CLAIMANT)

INSTRUCTIONS TO CLAIMANT
On the reverse, itemize the claim and show the date the service was rendered or the debt incurred. Describe the item or service in
detail, and indicate the amount claimed for each item. Do not include debts incurred after the date of death, except funeral claims.
If the claim is not due or contingent, or the amount is not yet ascertainable, state the facts supporting the claim.
If the claim is secured by a note or other written instrument, the original or a copy must be attached (state why original is
unavailable.) If secured by mortgage, deed of trust, or other lien on property that is of record, it is sufficient to describe the security
and refer to the date or volume and page, and county where recorded. (See Prob. Code, § 9152.)
Mail or take this original claim to the court clerk's office for filing. If mailed, use certified mail, with return receipt requested.
Mail or deliver a copy to the personal representative and his or her attorney. Complete the Proof of Mailing or Personal Delivery on
the reverse.
The personal representative or his or her attorney will notify you when your claim is allowed or rejected.
Claims against the estate by the personal representative and the attorney for the personal representative must be filed within the
claim period allowed in Probate Code section 9100. See the notice box above.

Form Approved by the
Judicial Council of California
DE-172 [Rev. January 1, 1998]

(Continued on reverse)
CREDITOR'S CLAIM
(Probate)

Probate Code, §§ 9000 et seq., 9153

ESTATE OF (Name):

CASE NUMBER:

DECEDENT

FACTS SUPPORTING THE CREDITOR'S CLAIM

See attachment (if space is insufficient)

Date of item

Item and supporting facts

Amount claimed

PROOF OF

MAILING

PERSONAL DELIVERY

$
TO PERSONAL REPRESENTATIVE

TOTAL:

(Be sure to mail or take the original to the court clerk's office for filing)

1.
2.
3.

I am the creditor or a person acting on behalf of the creditor. At the time of mailing or delivery I was at least 18 years of age.
My residence or business address is (specify):
I mailed or personally delivered a copy of this Creditor's Claim to the personal representative as follows (check either a or b below):
a.

Mail. I am a resident of or employed in the county where the mailing occurred.
(1)

I enclosed a copy in an envelope AND
(a)
(b)

deposited the sealed envelope with the United States Postal Service with the postage fully prepaid.
placed the envelope for collection and mailing on the date and at the place shown in items below following
our ordinary business practices. I am readily familiar with this business' practice for collecting and
processing correspondence for mailing. On the same day that correspondence is placed for collection and
mailing, it is deposited in the ordinary course of business with the United States Postal Service in a sealed
envelope with postage fully prepaid.

(2)

The envelope was addressed and mailed first-class as follows:
(a)
(b)
(c)

Name of personal representative served:
Address on envelope:
Date of mailing:
Place of mailing (city and state):

(d)

Personal delivery. I personally delivered a copy of the claim to the personal representative as follows:
(1)
(2)

Name of personal representative served:
Address where delivered:

(3)

(4)

Date of mailing:

Time delivered:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:

(TYPE OR PRINT NAME OF CLAIMANT)

(SIGNATURE OF CLAIMANT)

DE-172 [Rev. January 1,1998]

Page two

CREDITOR'S CLAIM
(Probate)

Creditor's Claim

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 2
Fields(s): 108
Average fields per page: 54
Reading Level: Grade 8
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

e_page_tex__1 was DE-172[0].Page1[0].TEXT\.0\.22\.4[0] (0.52 conf)
e_page_tex__2 was DE-172[0].Page1[0].TEXT\.0\.22\.0[0] (0.36 conf)
e_page_tex__3 was DE-172[0].Page1[0].TEXT\.0\.21[0] (0.36 conf)
e_page_std_p_info_county was DE-172[0].Page1[0].StdP1Header_sf[0].CourtInfo[0].CrtCounty_ft[0] (0.36 conf)
e_page_std_p_info_branch was DE-172[0].Page1[0].StdP1Header_sf[0].CourtInfo[0].Branch_ft[0] (0.37 conf)
e_page_std_p_info_city was DE-172[0].Page1[0].StdP1Header_sf[0].CourtInfo[0].CityZip_ft[0] (0.33 conf)
e_page_std_p_info_street was DE-172[0].Page1[0].StdP1Header_sf[0].CourtInfo[0].Street_ft[0] (0.37 conf)
e_page_std_p_header_info was DE-172[0].Page1[0].StdP1Header_sf[0].CourtInfo[0].MailingAdd_ft[0] (0.40 conf)
page_std_p_title_party_name was DE-172[0].Page1[0].StdP1Header_sf[0].TitlePartyName[0].TitlePartyName[0].Party_ft[0] (0.36 conf)
e_page_std_p_case_number was DE-172[0].Page1[0].StdP1Header_sf[0].CaseNumber[0].CaseNumber_ft[0] (0.34 conf)
page_std_p_header_info_text was DE-172[0].Page1[0].StdP1Header_sf[0].AttyPartyInfo[0].TextField1[0] (0.37 conf)
page_std_p_party_info_phone was DE-172[0].Page1[0].StdP1Header_sf[0].AttyPartyInfo[0].Phone[0] (0.37 conf)
page_std_p_party_info_email was DE-172[0].Page1[0].StdP1Header_sf[0].AttyPartyInfo[0].Email[0] (0.37 conf)
e_page_decimal_field was DE-172[0].Page1[0].DecimalField1[0] (0.32 conf)
e_page_text_field__1 was DE-172[0].Page1[0].TextField2[0] (0.33 conf)
e_page_two__1 was DE-172[0].Page1[0].Two[0] (0.30 conf)
e_page_two__2 was DE-172[0].Page1[0].Two[1] (0.30 conf)
e_page_two__3 was DE-172[0].Page1[0].Two[2] (0.30 conf)
e_page_two__4 was DE-172[0].Page1[0].Two[3] (0.30 conf)
e_page_two__5 was DE-172[0].Page1[0].Two[4] (0.30 conf)
e_page_text_field__2 was DE-172[0].Page1[0].TextField2[1] (0.33 conf)
e_page_four__1 was DE-172[0].Page1[0].Four[0] (0.30 conf)
e_page_four__2 was DE-172[0].Page1[0].Four[1] (0.30 conf)
e_page_five_claimant was DE-172[0].Page1[0].FiveClaimant[0] (0.35 conf)
e_page_five__1 was DE-172[0].Page1[0].Five[0] (0.30 conf)
e_page_five__2 was DE-172[0].Page1[0].Five[1] (0.30 conf)
e_page_six__1 was DE-172[0].Page1[0].Six[0] (0.30 conf)
e_page_six__2 was DE-172[0].Page1[0].Six[1] (0.30 conf)
e_page_sig_date__1 was DE-172[0].Page1[0].SigDate[0] (0.36 conf)
e_page_sig_name__1 was DE-172[0].Page1[0].SigName[0] (0.36 conf)
e_page_tex__4 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[0] (0.36 conf)
e_page_tex__5 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[1] (0.36 conf)
e_page_tex__6 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[2] (0.36 conf)
e_page_tex__7 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[3] (0.36 conf)
e_page_tex__8 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[4] (0.36 conf)
e_page_tex__9 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[5] (0.36 conf)
e_page_tex__10 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[6] (0.36 conf)
e_page_tex__11 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[7] (0.36 conf)
e_page_tex__12 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[8] (0.36 conf)
e_page_tex__13 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[9] (0.36 conf)
e_page_tex__14 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[10] (0.36 conf)
e_page_tex__15 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[11] (0.36 conf)
e_page_tex__16 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[12] (0.36 conf)
e_page_tex__17 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[13] (0.36 conf)
e_page_tex__18 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[14] (0.36 conf)
e_page_tex__19 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[15] (0.36 conf)
e_page_tex__20 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[16] (0.36 conf)
e_page_tex__21 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[17] (0.36 conf)
e_page_tex__22 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.2[18] (0.36 conf)
e_page_tex__23 was DE-172[0].Page2[0].TEXT\.1\.15\.7\.3\.19\.20\.0\.0[0] (0.36 conf)
e_page__1 was DE-172[0].Page2[0].a[0] (0.37 conf)
e_page_total was DE-172[0].Page2[0].total[0] (0.37 conf)
e_page__2 was DE-172[0].Page2[0].s[0] (0.37 conf)
e_page_r was DE-172[0].Page2[0].r[0] (0.37 conf)
e_page_q was DE-172[0].Page2[0].q[0] (0.37 conf)
e_page_p was DE-172[0].Page2[0].p[0] (0.37 conf)
e_page__3 was DE-172[0].Page2[0].o[0] (0.37 conf)
e_page_n was DE-172[0].Page2[0].n[0] (0.37 conf)
e_page__4 was DE-172[0].Page2[0].m[0] (0.37 conf)
e_page_l was DE-172[0].Page2[0].l[0] (0.37 conf)
e_page_k was DE-172[0].Page2[0].k[0] (0.37 conf)
e_page_j was DE-172[0].Page2[0].j[0] (0.37 conf)
e_page__5 was DE-172[0].Page2[0].i[0] (0.37 conf)
e_page_h was DE-172[0].Page2[0].h[0] (0.37 conf)
e_page_g was DE-172[0].Page2[0].g[0] (0.37 conf)
e_page_f was DE-172[0].Page2[0].f[0] (0.37 conf)
e_page__6 was DE-172[0].Page2[0].e[0] (0.37 conf)
e_page__7 was DE-172[0].Page2[0].d[0] (0.37 conf)
e_page_c was DE-172[0].Page2[0].c[0] (0.37 conf)
e_page_b was DE-172[0].Page2[0].b[0] (0.37 conf)
e_page_subform_case_number_ft was DE-172[0].Page2[0].#subform[0].CaseNumber_ft[0] (0.41 conf)
e_page_subform_party_ft was DE-172[0].Page2[0].#subform[0].Party_ft[0] (0.32 conf)
e_page_check_box was DE-172[0].Page2[0].CheckBox34[0] (0.35 conf)
e_page_text_field__3 was DE-172[0].Page2[0].TextField3[0] (0.33 conf)
e_page_text_field__4 was DE-172[0].Page2[0].TextField21[0] (0.33 conf)
e_page_text_field__5 was DE-172[0].Page2[0].TextField20[0] (0.33 conf)
e_page_text_field__6 was DE-172[0].Page2[0].TextField19[0] (0.33 conf)
e_page_text_field__7 was DE-172[0].Page2[0].TextField18[0] (0.33 conf)
e_page_text_field__8 was DE-172[0].Page2[0].TextField17[0] (0.33 conf)
e_page_text_field__9 was DE-172[0].Page2[0].TextField16[0] (0.33 conf)
e_page_text_field__10 was DE-172[0].Page2[0].TextField15[0] (0.33 conf)
e_page_text_field__11 was DE-172[0].Page2[0].TextField13[0] (0.33 conf)
e_page_text_field__12 was DE-172[0].Page2[0].TextField14[0] (0.33 conf)
e_page_text_field__13 was DE-172[0].Page2[0].TextField12[0] (0.33 conf)
e_page_text_field__14 was DE-172[0].Page2[0].TextField11[0] (0.33 conf)
e_page_text_field__15 was DE-172[0].Page2[0].TextField10[0] (0.33 conf)
e_page_text_field__16 was DE-172[0].Page2[0].TextField9[0] (0.33 conf)
e_page_text_field__17 was DE-172[0].Page2[0].TextField8[0] (0.33 conf)
e_page_text_field__18 was DE-172[0].Page2[0].TextField7[0] (0.33 conf)
e_page_text_field__19 was DE-172[0].Page2[0].TextField6[0] (0.33 conf)
e_page_text_field__20 was DE-172[0].Page2[0].TextField5[0] (0.33 conf)
e_page_text_field__21 was DE-172[0].Page2[0].TextField4[0] (0.33 conf)
e_page_three__1 was DE-172[0].Page2[0].Three[0] (0.30 conf)
e_page_three__2 was DE-172[0].Page2[0].ThreeA1[0] (0.31 conf)
e_page_three__3 was DE-172[0].Page2[0].ThreeA1[1] (0.31 conf)
e_page_text_field__22 was DE-172[0].Page2[0].TextField2[0] (0.33 conf)
e_page_text_field__23 was DE-172[0].Page2[0].TextField2[1] (0.33 conf)
e_page_text_field__24 was DE-172[0].Page2[0].TextField2[2] (0.33 conf)
e_page_three__4 was DE-172[0].Page2[0].Three[1] (0.30 conf)
e_page_text_field__25 was DE-172[0].Page2[0].TextField2[3] (0.33 conf)
e_page_text_field__26 was DE-172[0].Page2[0].TextField2[4] (0.33 conf)
e_page_text_field__27 was DE-172[0].Page2[0].TextField2[5] (0.33 conf)
e_page_proof__1 was DE-172[0].Page2[0].Proof[0] (0.30 conf)
e_page_proof__2 was DE-172[0].Page2[0].Proof[1] (0.30 conf)
e_page_sig_date__2 was DE-172[0].Page2[0].SigDate[0] (0.36 conf)
e_page_sig_name__2 was DE-172[0].Page2[0].SigName[0] (0.36 conf)
e_page_text_field__28 was DE-172[0].Page2[0].TextField2[6] (0.33 conf)
e_page_text_field__29 was DE-172[0].Page2[0].TextField2[7] (0.33 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Creditor's Claim

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02