(Rev. 8/20/04) CCP 0608 A SMALL ESTATE AFFIDAVIT (to be used only when decedent died on or after September 4, 1991.) I, ___________________________________________________________________________________________, on oath state: (name of affiant) 1. (a) My post office address is: _____________________________________________________________________________ (b) My residence address is: _____________________________________________________________________________ (c) I understand that, 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/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 of County, Illinois, is recognized by Illinois law as my agent for 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 certificate. 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. (Attach a list of each asset, e.g. cash, stock and its fair market value.)* Strike either 7(a) or 7(b).) 7. (a) *All of the decedent's funeral expenses have been paid, or (b) *The amount of the decedent's unpaid funeral expenses and the name and post office address of each person entitled thereto are as follows: Name and post office address Amount 8. There is no known unpaid claimant or contested claim against the decedent, except as stated in paragraph 7. 9. (a) The name and places of residence of any surviving spouse, minor child(ren) and adult dependent child(ren)* 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 him/herself and is likely to become a public charge.) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (OVER) (Rev. 8/20/04) CCP 0608 B (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 child(ren) and adult dependent child(ren) who resided with the surviving spouse at the time of decedent's death. If any such child(ren) 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 minor child(ren) and adult dependent child(ren) of a decedent who was an Illinois resident is $ _______________________ ($10,000 plus $5,000 multiplied by the number of minor child(ren) and adult dependent child(ren), to be divided among them in equal shares.) (Strike either 10 (a) or 10 (b).) 10. a)*The decedent left no will. The names, places of residence and relationship of the decedent's heir is, and the portion of the estate to which each heir is entitled under the law where decedent died intestate are as follows: Name, relationship and place of residence Age of minor 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 admissible to probate. The names and places of residence of the legatees and the portion of the estate, if any, to which each legatees is entitled are as follows: Name, relationship and place of residence Age of minor Portion of estate (c) Affiant is unaware of any dispute or potential conflict as to the heirship or will of the decedent. 11. The property described in paragraph 6 of this affidavit should be distributed as follows: Name Specific sum or property to be distributed THE FOREGOING STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY.* _______________________________________ Signature of Affiant (Note: A FRAUDULENT STATEMENT MADE UNDER THE PENALTIES OF PERJURY IS PERJURY, AS DEFINED IN SECTION 32-2 OF THE CRIMINAL CODE OF 1961.) DOROTHY BROWN, CLERK OF THE CIRCUIT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form