IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT KANE COUNTY, ILLINOIS Case No. Plaintiff(s) Defendant(s) File Stamp SMALL ESTATE AFFIDAVIT (SEA) Chapter 755 ILCS 5/25-1 Illinois Revised Statutes Payment of delivery of small estate of decedent upon affidavit (a) When any person or corporation (1) indebted or holding personal estate of a decedent, (2) controlling the right of access to decendent's safe deposit box or (3) acting as a registrar or transferagent of any evidence of interest, indebtedness, property or right is furnished with a small estate affidavit in substantially the form hereinafter set forth such person or corporation shall pay the indebtedness, grant access to the safe deposit box, deliver the personal estate or transfer or issue the evidence of interest, indebtedness, property or right to persons and in the manner specified in paragraph 11 of the affidavit or to an agent appointed as hereinafter set forth. I, on oath state: (1) (a) my post office address is (b) my residence address is (c) I understand, 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 & ZIP CODE TELEPHONE (IF ANY) 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 attorney who prepared this affidavit on my behalf is recognized by Illinois law as my agent for the 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 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. (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. (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: (check either (a) or (b)) NAME AND POST OFFICE ADDRESS AMOUNT (8) There is no known unpaid claimant or contested claim against the decedent, except as stated in paragraph 7. (9) (a)The names and places of residence of any surviving spouse, minor children and adult dependent* children of the decedent are as follows: (*NOTE: An adult dependent child is one who is unable to maintain him/herself and is likely to become a public charge) NAME AND RELATIONSHIP PLACE OF RESIDENCE AGE OF MINOR CHILD P2-P-011 Page 1 of 2 (04/09) American LegalNet, Inc. www.FormsWorkflow.com Case No. SMALL ESTATE AFFIDAVIT CONTINUED ($10,000, plus (b) The award allowable to the surviving spouse of a decedent who was an Illinois resident is $5,000 multiplied by the number of minor children and adult dependent children, who resided with the surviving spouse at the time of the 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 the minor children and adult dependent children of the decedent who was an Illinois resident is ($10,000, plus $5,000 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 relationship of the decedent's heirs, and the portion of the estate to which each heir is entitled under the law where the decedent died intestate are as follows: OR (b) The decedent left a will, which has been filed with the Clerk of the 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 admissible to probate. The names and places of residence of the legatees and the portion of the estate, if any, to which each legatee is entitled are as follows: (check either paragraph (a) or (b)) NAME, RELATIONSHIP & PLACE OF RESIDENCE AGE OF MINOR CHILD PORTION OF THE ESTATE (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.* Signature of Affiant (Note: A fraudulent statement made under the penalties of perjury is perjury as defined in section 32-2 of the Criminal Code of 1961) (c) Appointment of Agent. If safe deposit access is involved or if sale of any personal property is desirable to facilitate distribution pursuant to the small estate affidavit, all persons named in paragraph 11 of the small estate affidavit (excluding minors and unascertained or disabled persons) may in writing appoint one or more persons as their agent for that purpose. The agent shall have power without court approval, to gain access to, sell, and distribute the property for the benefit of all persons named in paragraph 11 of the affidavit; the payment, delivery, transfer, access or issuance shall be made or granted to or on the order of the agent. (d) Release. Upon payment, delivery, transfer, access or issuance pursuant to a properly executed affidavit, the person or corporation is released to the same extent as if the payment, delivery, transfer, access or issuance had been made or granted to the representative of the estate. Such person or corporation is not required to see the application or disposition of the property; but each person to whom a payment, delivery, transfer, access or issuance is made or given is answerable therefore to any representative of the estate. (e) The affiant signing the small estate affidavit prepared pursuant to subsection (b) of this Section shall indemnify and hold harmless all creditors and heirs of the decedent and other person replying upon the affidavit who incur loss because of such reliance. That indemnification shall only be up to the amount lost because of the act or omission of the affiant. Any person recovering under this subsection (e) shall be entitled to reasonable attorney's fees and the expenses of recovery. (f) The affiant of a small estate affidavit who is a non-resident of Illinois submits himself or herself to the jurisdiction of Illinois courts for all matters related to the preparation or use of the affidavit. The affidavit shall provide the name, address and phone number of a person who the affiant names as his/her agent for the service of process. If no such person is named or if, for any reason, service on the named person cannot be effectuated, the Clerk of the Circuit Court of the County or Judicial Circuit of which the decedent was a resident at the time of his/her death shall be the agent for the service of process. P2-P-011 Page 2 of 2 (04/09) American LegalNet, Inc. www.FormsWorkflow.com