Verified Claim Form – Fill Out and Use This PDF

SURROGATE'S COURT OF THE STATE OF NEW YORK -	COUNTY
____________________________________
In the Matter of the Estate of	VERIFIED CLAIM
	FILE # ___________________________
Deceased
____________________________________

To a fiduciary to whom Letters were issued for the above named estate:

Fiduciary Name:____________________________________________________________________________________

Fiduciary Complete Address:_______________________________________State:______________Zip:_____________

1.	The undersigned is the owner and holder of a claim against the above named estate.
2.	The claim is in the amount of $		.
3.	The facts upon which the claim is based are as follows:_________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

4.	A copy of an invoice, statement or voucher [ ] is / [ ] is not attached.
5.	No payments have been made upon the amount claimed except as follows:__________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

6.No offsets against this claim exist, except as follows:_____________________________________________________

_________________________________________________________________________________________________

7.The claimant holds no security, except as follows:_______________________________________________________

_________________________________________________________________________________________________

_______________________________________		_______________________________________
Corporate Claimant		Claimant
_______________________________________		_______________________________________
Corporate Officer		Print Name
		VERIFICATION
State of New York	}
County of	} ss:
[Individual]

I am the claimant of the foregoing claim; the claim is true to my own knowledge, except as to matters stated upon information

and belief and as to those matters I believe them to be true.
[Corporation]
I am the	of

the corporation named as claimant; I have read the foregoing claim and know the contents thereof; the same is true of my own knowledge, except as to the matters therein stated to be alleged upon information and belief, and as to those matters I believe it to be true; the reason why this verification is made by me and not by claimant is that the claimant is a corporation; the source of my information and the greounds of my belief as to all matters in claim not stated upon my own knowledge are investigations which I have made or caused to be made concerning the subject matter of this claim and information acquired by me in the course of my duties as an officer of the corporation.

Subscribed and sworn to before me			_______________________________
on this	Day of	,	Claimant
		Address:	_______________________________
___________________________			_______________________________

Notary Public		My commission expires:
Attorney for Claimant Name		Tel. No.
Address:

[A copy of the claim must be given to the fiduciary in person or by certified mail, return receipt requested. See SCPA §1803(2). You may use the attached form for the affidavit of mailing and attach the return receipt (green card).]

NYSBA's Surrogate's Court Form, Verified Claim