Creditors Claim {3C-E-023}

STATE OF HAWAI221I CIRCUIT COURT OF THE THIRD CIRCUIT CREDITOR222S CLAIM CASE NUMBER P. No. THE ESTATE OF DECEASED CLAIMANT222S NAME, ADDRESS, AND TELEPHONE NO. AMOUNT OF CLAIM PER CERTIFIED STATEMENT ATTACHED STATE OF HAWAI324I CITY & COUNTY OF ) ) SS ) Affiant being first duly sworn, on oath deposes and says; that affiant makes this claim in the capacity stated below; that the foregoing claim amounting to the sum indicated against the estate of the above named deceased is justly due and owing. No payments have been made which have not been credited and that there are no offsets against the claim, to the knowledge of this affiant. AFFIANT222S NAME AND TITLE SIGNATURE SUBSCRIBED AND SWORN BEFORE ME THIS DATE: NOTARY PUBLIC/CLERK STATE OF HAWAI221I MY COMMISSION EXPIRES: FOR COURT USE ONLY In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the Circuit Court Administration Office at PHONE NO. 961-7440, FAX 961-7416, or TTY 961-7525 at least ten (10) working days prior to your hearing or appointment date. Reprographics (03/07) CREDITOR222S CLAIM 3C-E-023 American LegalNet, Inc. www.FormsWorkFlow.com