IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS SMALL ESTATE AFFIDAVIT I, ________________________________________, Affiant, on oath state; 1. (a) My post office address is:________________________________________ City:__________________________State:_______________Zip___________ (b) My residence address is:_________________________________________ City:__________________________State:_______________Zip:___________ (c) My telephone number is:_________________________________________ (d) 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:___________________________________________________________ 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 (of the ____________________ Judicial Circuit), 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 decedent’s death certificate hereto. 4. The decedent’s place of residence immediately before 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. Page 1 of 4 PRO00007PRO REV: 3/1/05 American LegalNet, Inc. www.FormsWorkflow.com 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 (Here, list each asset, e.g. cash, stock, and its fair market value.) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 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 _______________________________________ _______________ _______________________________________ _______________ _______________________________________ _______________ _______________________________________ _______________ (Strike either 7(a) or 7(b). 8. There is no known unpaid claimant or contested claim against the decedent, except as stated in Paragraph 7 above. 9. (a) The names and places of residence of any surviving spouse, minor children and adult dependent* children 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 himself and is likely to become a public charge.) Page 2 of 4 PRO00007PRO REV: 3/1/05 American LegalNet, Inc. www.FormsWorkflow.com (b) The award allowable to the surviving spouse of a decedent who was an Illinois resident is $__________________ ($10,000.00, plus $5,000.00 multiplied by the number of minor children and adult dependent children who resided with the surviving spouse at the time of decedent’s death. If any such child 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 children and adult dependent children of a decedent who was an Illinois resident is $_______________ ($10,000.00, plus $5,000.00 multiplied by the number of minor children and adult dependent children), to be divided among them in equal shares. 10. (a) The decedent left no will. The names, places of residence and relationships of the decedent’s heirs, 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 admittable to probate. The names and places of residents of the legatees and the portion of the estate, if any, to which each legatee is entitled are as follows: Name, Relationship and Place of Residence Age of Minor Portion of Estate ____________________________________ ________ ________________ ____________________________________ ________ ________________ ____________________________________ ________ ________________ ____________________________________ ________ ________________ (Strike either 10(a) or 10(b). Page 3 of 4 PRO00007PRO REV: 3/1/05 American LegalNet, Inc. www.FormsWorkflow.com (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.* ________________________________ Date ______________________________ Signature of Affiant Subscribed and sworn to before me, a Notary Public this __________day of _______________________, 20____. ________________________________________ Signature of Notary Public (Notary Public Seal) *(NOTE: A FRAUDULENT STATEMENT MADE UNDER THE PENALTIES OF PERJURY IS PERJURY, AS DEFINED IN SECTION 32-2 OF THE CRIMINAL CODE OF 1961.) Page 4 of 4 PRO00007PRO REV: 3/1/05 American LegalNet, Inc. www.FormsWorkflow.com