SMALL ESTATE AFFIDAVIT 3764 (Rev. 7/15) Page 1 of 3 755 ILCS 5/25-1 Payment or delivery of small estate of decedent upon affidavit (a) When any person, corporation, or financial institution (1) indebted to or holding personal estate of a decedent, (2) controlling the right of access to the decedent's safe deposit box, or (3) acting as registrar or transfer agent of any evidence of interest, indebtedness, property or right is furnished with a small estate affidavit in substantially the form hereinafter set forth, that person, corporation, or financial institution shall pay the indebtedness, grant access to the safe deposit box, deliver the personal estate or transfer or issue the evidence of interest, indebtedness, property or right to persons and in the manner specified in the affidavit or to an agent appointed as hereinafter set forth. STATE OF ILLINOIS I 1. (a) my post office address is SMALL ESTATE AFFIDAVIT COUNTY OF DU PAGE on oath state: (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 18th Judicial Circuit Court of DuPage County is recognized by Illinois law as my agent for service of process. 2. The decedent's name is , and I have attached a copy of the death certificate hereto. 3. The date of the decedent's death was 4. The decedent's place of residence immediately before his death was 5. No letters of office 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. (a) All of the decedent's funeral expenses and other debts have been paid, or (b) All of the decedent's known unpaid debts are listed and classified as follows (include the name, post office address, and amount) 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: 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: (Strike either 7(a) or 7(b)). CHRIS KACHIROUBAS, CLERK OF THE 18TH JUDICIAL CIRCUIT© COURT WHEATON, ILLINOIS 60187-0707 American LegalNet, Inc. www.FormsWorkFlow.com SMALL ESTATE AFFIDAVIT Page 2 of 3 3764 (Rev. 7/15) 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 dependant* children of the decedent are as follows: NAME AND RELATIONSHIP PLACE OF RESIDENCE AGE OF MINOR CHILD *(NOTE: An adult dependant 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 $ ($20,000, plus $10,000 multiplied by the number of minor children and adult dependant 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 dependant children of the decedent who was an Illinois resident is $ ($20,000 plus $10,000 multiplied by the number of minor children and adult dependant children), to be divided among them in equal shares. 10. (a) The decedent left no will. The names, places of residence and relationships 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: NAME, RELATIONSHIP & PLACE OF RESIDENCE AGE OF MINOR CHILD PORTION OF ESTATE OR (b) the decedent left a will, which has been filed with the Clerk of an appropriate court. A certified copy of the will on file is attached. To the best of my knowledge and belief the will on file 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 ESTATE (strike either10(a) or 10(b). (c) Affiant is unaware of any dispute or potential conflict as to the heirship or will of the decedent. 10.3 My relationship to the decedent or 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, corporat