3764 (Rev. 12/04) SMALL ESTATE AFFIDAVIT 755 ILCS 5/25-1 Payment or delivery of small estate of decedent upon affidavit (a) When any person or corporation (1) indebted to or holding personal estate of a decedent, (2) controlling the right of access to the decedent's safe deposit box, or (3) acting as a registrar or transfer agent of any evidence of interest, 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 manner specified in paragraph 11 of the affidavit or to an agent appointed as hereinafter set forth. STATE OF ILLINOIS SMALL ESTATE AFFIDAVIT COUNTY OF KENDALL on oath states: I 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/State/Zip: 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 18th Judicial Circuit Court of DuPage County is recognized by Illinois law as my agent for the service of process. 2. The decedent’s name is 3. The date of the decent’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: (strike 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 dependant* children of the decedent are as follows: NAME AND RELATIONSHIP PLACE OF RESIDENCE AGE OF MINOR CHILD (*NOTE: An adult dependant child is one who is unable to maintain himself and is likely to become a public charge.) (b) the award allowable to the surviving spouse of a decedent who was an Illinois resident is $ ($10,000, plus $5,000 multiplied by the number of minor children and adult dependant 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 dependant children of the decedent ($10,000 plus $5,000 multiplied by the number of minor who was an Illinois resident is $ children and adult dependent children), to be divided among them in equal shares. BECKY MORGANEGG, CLERK OF THE 16TH JUDICIAL CIRCUIT COURT YORKVILLE, ILLINOIS 600560 American LegalNet, Inc. www.USCourtForms.com 3764 (Rev. 12/04) SMALL ESTATE AFFIDAVIT 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 admittable 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: (strike (a) or (b) NAME, RELATIONSHIP& PLACE OF RESIDENCE AGE OF MINOR CHILD PORTION OF ESTATE (c) Affiant is unaware of any dispute or potential conflict as to the heirship of 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 720 ILCS 5/32-2) (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 claims 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 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 to a properly executed affidavit, the person or corporation is released to the same extent as if the 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 subsections (b) of this Section shall indemnify and hold harmless all creditors and heirs of the decedent and other persons relying 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 the person who the affiant names as his agent for the service process. If no such person is named or if, for any reason, service on the 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 process. BECKY MORGANEGG, CLERK OF THE 16TH JUDICIAL CIRCUIT COURT American LegalNet, Inc. YORKVILLE, ILLINOIS 600560 www.USCourtForms.com