Estate of 

First, middle, and last name

Creditor’s name

I, 

 

 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:

 Notice to interested persons: This is a claim by a personal representative for an obligation that arose before the death of the
  decedent. Upon petition and notice to interested persons, 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 the 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.

Name (type or print)                                                                         Bar no.

Claimant signature

Attorney signature

Address

Date

Address

 

 

 

 

City, state, zip                                                                        Telephone no.

City, state, zip                                                                              Telephone no.

    assignee.

*  1. Describe nature of claim or attach a statement. Attach copy of receipt or other evidence of payment if submitted by    
 
    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).

USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.

(SEE SECOND PAGE)

Do not write below this line - For court use onlyPC 579 (12/17) STATEMENT AND PROOF OF CLAIMMCL 700.3804, MCL 700.5429, MCL 700.7609, MCR 5.208(E), MCR 5.307(D)Approved, SCAO JIS CODE: SPCSTATE OF MICHIGANPROBATE COURTCOUNTY OFSTATEMENT AND PROOF OF CLAIMFILE NO.PROOF OF SERVICE

File No. 
 

I served upon 

Name

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

 by 

Date

State method and address of service

 ,

 .

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

Date

Service of the attached statement and proof of claim is acknowledged.

ACKNOWLEDGMENT OF SERVICE

 

 

Signature

Signature

Statement and Proof of Claim (12/17)