CIRCUIT COURT OF ILLINOIS Sixth Judicial Circuit Champaign County SMALL ESTATE AFFIDAVIT I, , on oath state: 1. (a) My post of¿ce address is . (b) My residence address is . (c) I understand, if I am an out-of-state resident, I submit myself to the jurisdiction of Illinois courts for all matters related to the preparation and use of this Affidavit. My agent for service of process in Illinois is: Name: Address: City/State/Zip: Telephone: I understand that if no person is named above as my agent for service, or, if for any reason, service on the named person cannot be effectuated, the Clerk of the Circuit Court is recognized by Illinois law as my agent for the service of process. 2. The decedent's name is 3. The date of the decedent's death was , and I have attached a copy of the death certi¿cate. 4. The decedent's place of residence immediately before death was . 5. No letters of of¿ce are now outstanding on the decedent's estate and no petition for letters is contemplated or pending in Illinois or in any other jurisdiction, to my knowledge. 6. The gross value of the decedent's entire personal estate, including the value of all property passing to any party either by intestacy or under a will, does not exceed $100,000 (list each asset, e.g. cash, stock and its fair market value): . 7. All of the decedent's funeral expenses have been paid, or All the amount of the decedent's unpaid debts are listed and classified as follows (include the name, post office address, and amount) funeral expenses and the name and post of¿ce address of each person entitled thereto are as follows: AMOUNT NAME AND POST OFFICE ADDRESS Class 1: funeral and burial expenses, which include reasonable amounts paid for a burial space, crypt, or niche; a marker on the burial space; and care of the burial space, crypt, or niche; expenses of administration, and statutory custodial claims as follows: Class 2: the surviving spouse's award or child's award, if applicable, as follows: Page 1 of 3 - Small Estate Affidavit Revised: 07/05; 06/10; 01/15 Katie M. Blakeman Clerk of the Sixth Judicial Circuit Court 101 E. Main Street Urbana, Illinois 61801 American LegalNet, Inc. www.FormsWorkFlow.com Class 3: debts due the United States, as follows: Class 4: money due employees of the decedent of not more than $800 for each claimant for services rendered within 4 months prior to the decedent's death and expenses attending the last illness, as follows: Class 5: money and property received or held in trust by the decedent which cannot be identified or traced, as follows: Class 6: debts due the State of Illinois and any county, township, city, town, village, or school district located within Illinois, as follows: Class 7: all other claims, as follows: 7.5 I understand that all valid claims against the decedent's estate described in paragraph 7 must be paid by me from the decedent's estate before any distribution is made to any heir or legatee. I further understand that the decedent's estate should pay all claims in the order set forth above, and if the decedent's estate is insufficient to pay the claims in any one class, the claims in that class shall be paid pro rata. 8. There is no known unpaid claimant or contested claim against the decedent, except as stated in paragraph 7. 9. (a) The names and places of residence of any surviving spouse, minor children, and adult dependent* children of the decedent are as follows: NAME AND RELATIONSHIP PLACE OF RESIDENCE AGE OF MINOR CHILD (*NOTE: An adult dependent child is one who is unable to maintain himself and is likely to become a public charge.) (b) The award allowable to the surviving spouse of a decedent who was an Illinois resident is $ ($10,000, plus $5,000 multiplied by the number of minor children and adult dependent children who resided with the surviving spouse at the time of the decedent's death. If any such child did not reside with the surviving spouse at the time of the decedent's death, so indicate. (c) If there is no surviving spouse, the award allowable to the minor children and adult dependent children of the decedent who was an Illinois resident is $ ($10,000, plus $5,000 multiplied by the number of minor children and adult dependent children), to be divided among them in equal shares. 10. The decedent left no will. The names, places of residence, and relationship of the decedent's heirs, and the portion of the estate to which each heir is entitled under the law where the decedent died intestate are as follows: the decedent left a will, which has been ¿led with the Clerk of the appropriate court. A certi¿ed copy of the will on ¿le is attached. To the best of my knowledge and belief, the will on ¿le is the decedent's last will and was signed by the decedent and the attesting witnesses as required by law and would be admittable to probate. The names and places of residence of the legatees and the portion of the estate, if any, to which each legatee is entitled are as follows: NAME, RELATIONSHIP & PLACE OF RESIDENCE AGE OF MINOR CHILD PORTION OF THE ESTATE Af¿ant is unaware of any dispute or potential conÀict as to the heirship of the will of the decedent. Page 2 of 3 - Small Estate Affidavit Katie M. Blakeman Clerk of the Sixth Judicial Circuit Court 101 E. Main Street Urbana, Illinois 61801 American LegalNet, Inc. www.FormsWorkFlow.com 10.3 My relationship to the decedent of the decedent's estate is as follows: 10.5 I understand that the decedent's estate must be distributed first to satisfy claims against the decedent's estate as set forth in paragraph 7.5 of this affidavit before any distribution is made to any heir or legatee. By signing this affidavit, I agree to indemnify and hold harmless all creditors of the decedent's estate, the decedent's heirs and legatees, and other persons, corporations, or financial institutions relying upon this affidavit who incur any loss because of reliance on this affidavit, up to the amount lost because of any act or omission by me. I further understand that any person, corporation, or financial institution recovering under this indemnification provision shall be entitled to reasonable attorney's fees and the expenses of recovery. 11. After payment by me from the decedent's estate of all debts and expenses listed in paragraph 7, any remaining property described in paragraph 6 of this Af¿davit should be distributed as follows: NAME SPECIFIC SUM OR PROPERTY TO BE DISTRIBUTED The foregoing statement is made under the penalties of