Form PE34
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No._____________________
In re ESTATE OF
WRITTEN STATEMENT OF CLAIM
DIRECTIONS: In the space below, state your claim against the estate. Your statement
must include a description of the claim, the amount claimed and a description of the
security for your claim, if any. You must attach documentation of your claim.
Description of Claim
Amount Owed
Security for
Claim, if any
$
$
Use additional sheets if necessary.
You must deliver or mail your claim to the Fiduciary (Administrator or
Executor) of the Estate and you must file a copy with the Court.
Name of Fiduciary
Fiduciary’s Address
Name and Address of Court
Dated
Signature
Name Printed
Address
Phone Number
( )
Email Address
Decedent
Y
N
Y
N
SML 11/12