IN THE CIRCUIT COURT FOR THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS IN THE MATTER OF THE ESTATE OF __________________________________ Case No.__________________________________ TYPE OF ESTATE: [ ] A deceased person [ ] A disabled person [ ] A minor -----------------------------------------------------------NAME OF REPRESENTATIVE AND OF OFFICE: Name: [ ] Administrator [ ] Executor [ ] Guardian [ ] Other -----------------------------------------------------------ATTORNEY FOR REPRESENTATIVE: Name: Address: City: State: Zip: -----------------------------------------------------------DISTRIBUTEE: Name: Address: City: State: Zip: RECEIPT ON DISTRIBUTION The undersigned hereby acknowledges receipt of: [ ] Partial [ ] Full distribution of the share of the undersigned estate as follows: The undersigned hereby appears, waives notice and consents to the approval of the following document(s) of the representative and acknowledges and consents to the allowance of fees to the Representative and attorney as set forth in the indicated document: [ ] Current Account [ ] Final Account [ ] Final Report and Account [ ] Final Report of Independent Representative (the Distributee acknowledging receipt of the Inventory and Final Account) Telephone: ------------------------------------------------------------- __________________________________________ Distributee __________________________________________ Dated Probate31\Receipt on Distribution Rev.: 11/16/2012 American LegalNet, Inc. www.FormsWorkFlow.com