CIRCUIT COURT OF ILLINOIS Sixth Judicial Circuit Champaign County IN THE MATTER OF THE ESTATE OF ___________________________________ Deceased Case No: _____________________ ESTATE CLAIM Name of Claimant: _______________________________________________________________________ Address: _______________________________________________________________________________ City/State/Zip Code: ______________________________________________________________________ Telephone: _____________________________________________________________________________ ============================================================================= Statement of Claim: Amount of Claim $___________________ ============================================================================= The undersigned, being duly sworn, states that said Estate is indebted to the above named Claimant, after allowing all just credits and set-offs, in the amount set forth above, and attached hereto is a true itemized statement of said claim or a true copy of original promissory note and endorsements thereon. Subscribed and sworn to before me this ______ day of ____________________, 20____. ____________________________________ Notary Public ­ Circuit Clerk _______________________________________ Claimant By ____________________________________ Claimant's duly authorized agent ============================================================================= This claim allowed by Court in the sum of Now comes the undersigned personal representative of the above named Estate and enters his/her appearance $_________________ as of the __________ class. and consents / objects to the allowance of said claim this ____ day of ________________, 20___. Judgment in favor of the Claimant and against Estate in said amount. __________________________________ Executor - Administrator Entered: ____________________________________ Judge Date:_____________________________________ Revised: 11/99; 06/10 Katie M. Blakeman Clerk of the Sixth Judicial Circuit Court 101 E. Main Street Urbana, Illinois 61801 American LegalNet, Inc. www.FormsWorkFlow.com