State of South Dakota ) In Circuit Court
County of ________ ) ss ______________ Judicial Circuit
)
Estate of )
____________________ ) FILE NO.____________
Deceased )
This claim is made against the estate:
Description of Claim Due Date, If Not Yet Due Amount
1._______________________ ____________________ $__________
2._______________________ ____________________ $__________
3._______________________ ____________________ $__________
4._______________________ ____________________ $__________
5._______________________ ____________________ $__________
TOTAL CLAIM $__________
* This claim is unsecured.
* This claim is secured by __________.
* This claim is contingent or unliquidated because __________.
__________.
Dated _______.
__________
Claimant's Signature
__________
Claimant's Name
__________
Claimant's Address
__________
Claimant's Telephone Number
(The following information shall appear on the back of the Statement of Claim form)
How To Use This Form:
1. Filing the Statement of Claim with the clerk of courts and mailing a copy to the personal representative, or
2. Mailing or delivering the Statement of Claim to the personal representative. (A proof of notice should be filed with the clerk if the Statement of Claim is mailed to the personal representative.)
Comments:
Source: SL 1997, ch 348 (Supreme Court Rule 97-43).