AFFIDAVIT OF HEIRSHIP (COLLATERIAL HEIRS/NO DESCENDENTS) - PROBATE STATE OF ILLINOIS 3841 (Rev. 4/17) UNITED STATES OF AMERICA COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT IN RE THE ESTATE OF CASE NUMBER DECEASED File Stamp Here AFFIDAVIT OF HEIRSHIP COLLATERIAL HEIRS (NO DESCENDENTS) The undersigned, on oath states: 1. The decedent, died on 2. I am of legal age, I reside at I am a Relationship at at the age of of the decedent. I am not related to the decedent, but have knowledge of decedent's heirship as a result of the following: 3. The decedent was never married The decedent was married Number of Marriages The following is the information with respect hereto: Name of Spouse 1. 2. 3. 4. No child was born or adopted by decedent. 5. The decedent's parents were: Father Mother Survived Survived Predeceased Decedent Predeceased Decedent Marriage Terminated (by death or divorce) Predeceased Decedent - P CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF HEIRSHIP (COLLATERIAL HEIRS/NO DESCENDENTS) - PROBATE 3841 (Rev. 4/17) 6. The following children were born or adopted by decedent's parents: Brothers or Sisters Name 1. 2. 3. 4. Predeceased P Spouses Name if Married 7. The above (section 6) brothers and sisters who predeceased the decedent and who had children born or adopted. Name of Niece or Nephew 1. 2. 3. 4. By Brother or Sister Number Predeceased P Spouses Name if Married 8. The above (section 7) nieces and nephews who predeceased the decedent and who had children born or adopted. Name of Great Niece or Nephew 1. 2. 3. 4. By Niece or Nephew Number Predeceased P Spouses Name if Married Based on the foregoing, decedent left surviving as his or her heirs the following, all of whom survived the decedent, and in the absence of any indication of the contrary, are of legal age, are mentally competent, and if children, are natural children. Date Affiant Name: DuPage Attorney Number: Attorney for: Address: City/State/Zip: Telephone Number: Email: Pro Se Subscribed and sworn to before me Date Circuit Clerk or Notary Public CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © American LegalNet, Inc. WHEATON, ILLINOIS 60187-0707 Page 2 of 2 www.FormsWorkFlow.com