WHEN CLAIM IS BASED UPON A WRITTEN INSTRUMENT, A COPY OF THE INSTRUMENT MUST BE ATTACHED. Claim on Contract Rev. 12-27-2017 IN THE CIRCUIT COURT FOR THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS In the matter of the ESTATE OF: ) Case No. ) ) ) CLAIM ON CONTRACT CLAIMAN T: Name: Address: City/State/Zip: AMOUNT OF CLAIM $ Mailing and Delivery of Copy of Claim Waived By: [ ] Executor [ ] Administrator [ ] Guardian [ ] Conservator [ ] Attorney for Estate Date: See 755 ILCS 5 - 18 - 1 et. seq. I certify that on the date set forth below that a copy of this Claim was: [ ] Delivered in Person [ ] Mailed by Registered Mail [ ] Mailed by Ordinary Mail TO: [ ] Executor [ ] Administrator [ ] Guardian [ ] Conservator AND: Attorney for Estate Signed: Attorney or Agent for Claimant Date: CONSENT I consent to Allowance of the Claim and Cost of Filing Be Charged to the Estate. Date: Amount: $ Class: Signed: [ ] Executor [ ] Administrator [ ] Guardian [ ] Conservator [ ] Attorney for Estate ORDER Date: [ ] All for $ Class Judge ORDER Date: [ ] Found paid and satisfied. [ ] Dismissed. Judge The within named Claimant makes claim against the Estate for the amount shown and for reason stated in the space below and on oath says he/she is the Claimant; he/she has knowledge of the facts relating to the claim; the statements are true; the claim is just and unpaid after allowing all just credits, deductions and set offs. Date: Claimant or Representative of Claimant (If Representative, must state office held) Signed and sworn to before me , 20. (Clerk of Court - Notary) Attorney for Claimant: Address: City/State/Zip: Telephone: ITEMIZED STATEMENT OF CLAIMS (Attach separate sheet for more information.) American LegalNet, Inc. www.FormsWorkFlow.com