E LE CTION TO TAKE GOODS AND CHATTELS FOR AWARD 3791(Rev. 07/05) UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT ESTATE OF CASE NUM BER File Stamp Here EL ECTION TO TAKE GOODS AND CHATTEL S FOR AWARD I (Surviving Spouse) (Guardian for Minor) (Adult Dependent Child) of the deceased, elect to take the goods and chattels listed below at their appraised value to apply against the award of $ and to take (Surviving Spouses) (Childs) the balance of in cash. $ GOODS AND CHATTELS APPRAISED VALUE Total $ Name: PRO SE DuPage Attorney Number: Attorney for: Signature Address: Dated City/State/Zip: Telephone: CHR IS KACHIR OUBAS, CL ERK OF THE 18TH J UDICIAL CIRCUIT COURT WHEATON, ILL INOIS 60189-0707