2641 Claim (Rev. 11/19/03) CCP 0345 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS } Estate of ______________________________________ ORDER No. _____________________________ Docket __________________________ Page ___________________________ _______________, _______ Allowed for $____________ Class __________________ _________________________ Judge CLAIM 1. Claimant _______________________________________________________________________ has a claim for (name) $ ____________________________________ against this estate. 2. The nature of the claim* Atty. No.:_________________ _________________________________________________ Firm Name: ________________________________________ Address: ___________________________________________ Atty. for Claimant: _________________________________ Address: ___________________________________________ City/State/Zip:______________________________________ City/State/Zip: ______________________________________ Telephone: _________________________________________ Telephone: _________________________________________ *When the claim is based upon a written instrument, a copy of the instrument must be attached. When the claim is based on tort, so state. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Doc. ____________________ Page ________________ ________________, __________ No. _____________________ Mailing and delivery of copy of claim waived __________________________________________________ IN THE CIRCUIT COURT OF COOK COUNTY County Department - Representative Attorney for Representative =============================================== __________________, ________ Probate Division I ========================================= Estate of ________________________________________________ (certify) that on (state on oath) ____________________________, _________ a copy __________________________________________________ of this claim was (mailed) __________________________________________________ ======================== ======================= (delivered in person) to (mailed by ordinary mail) _______________________________________________ Representative CLAIM and to ___________________________________________ Attorney for Representative _________________________________________________________ ________________________________________________ Claimant Attorney or Agent for claimant (Agent's statement must be notarized) Signed and sworn to before me ______________________________________, _________ Amount of Claim $ _______________________________ ___________________________________________________ Notary Public ============================================ ===================================== _________________, _________ I consent to the allowance of this claim for $ ________________ as a claim of the _________________ class. Set for hearing _____________________, _________ __________________________________________________ Representative Attorney for Representative at ______________ m. in Room ___________________ ============================= ============================= RICHARD J. DALEY CENTER =============================== ============================== Chicago, Illinois 60602 ============================================= (Rev. 11/19/03) CCP 0345 B Print This Form Date of letters _____________________________, _________ Unless the representative or his/her attorney waives in writing the mailing or delivery of a copy of the claim or consents in writing to the allowance of the claim, the claimant shall cause a copy of the claim to be mailed or delivered to the representative and to his/her attorney of record, if any, and shall file proof of such mailing or delivery within 10 days after the filing of the claim. For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form