IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT KANE COUNTY, ILLINOIS Case No. IN THE MATTER OF THE ESTATE OF DECEDENT/MINOR: Name: Address: City, State, Zip: Date of Death (Decedent): Date of Birth (Minor): File Stamp RECEIPT ON DISTRIBUTION The undersigned hereby acknowledges receipt of : Specific Bequest Partial as distribution of their share of the above estate as follows: Full Residual Bequest (attach list if necessary) 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 in the amount of to the representative and in the amount of to the attorney. Current Account Final Account Final Report and Account Final Report of Independent Representative (the Distributee acknowledges receipt of the Inventory and Final Account) Date: Name of Distributee (please print): Signature of Distributee/Guardian: Address: City, State, Zip: Telephone No.: Administrator Attorney/Pro Se: Address: City, State, Zip: Telephone No.: Attorney Registration No.: Attorney E-mail: P1-PR-024 (11/12) American LegalNet, Inc. www.FormsWorkFlow.com Name of Representative: Executor Guardian Other