2753 REPORT OF ATTORNEY-IN-FACT OR CONSUL In accordance with Rule 12.19 of the Circuit Court of Cook County, states under the penalties of perjury: [printed name of attorney-in-fact or consul]1. An ORDER was entered on � , directing the representative of the estate to pay and deliver to me as � � � � � the distributive share of ; [printed name of the distributee]2. On , the share was paid and delivered to me;3. � I paid and delivered to the distributee the total amount received by me after deducting the expenditures set forth onthe RECEIPT of the distributee;4. Received by me: � Cash: � $ Total deductions authorized by distributee: � $ Net cash: � $ � � Property: � Paid and delivered to distributee: � Cash: � $ � Property: 5. The itemized Receipt of the distributee is attached. [signature of attorney-in-fact or consul] � [printed name of attorney-in-fact or consul] Dorothy Brown, Clerk of the Circuit Court of Cook CountyPage 1 of 1CCP-0387 (Rev. 10/1/2018) Case No. Calendar Estate of DeceasedIN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT 226 PROBATE DIVISION Attorney Number Name � Firm Name � Attorneys for � Address � City/State/Zip � Telephone � Email �