IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT, LAKE COUNTY, ILLINOIS PROBATE DIVISION ESTATE OF DECEASED. ) ) ) ) ) No. CLAIM AGAINST ESTATE 1. Claimant, name & address ______________________________________________has a claim for $ ____________against this Estate, which is just and unpaid after allowing all just credits, deductions and set-offs. 2. The nature of the claim is ______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________ Claimant AFFIDAVIT ________________________________ on oath states that the allegations in this claim are true. _______________________ signed and sworn to before me this _____________________, ______ ____________________________ Notary Public _______________________ ORDER Allowed for $ ___________ & costs. Class __________ ______________, ________ ______________________ JUDGE ______________________ Name ______________________ Attorney for _________________ Address _____________________ City & Zip ___________________ Telephone ___________________ 171P-21a Rev.10/00 2002 © American LegalNet, Inc. Mailing and delivery of copy of claim waived. Dated _____________________, ____ ____________________________________________________________________________________________ (Attorney for Estate) (Executor) (Administrator) (Guardian) NOTE: If claim is based upon a written instrument, a copy must be attached. ______________________________________________________________________________ Mailing and delivery of copy of claim waived. Dated ____________________, ______ (Attorney for Estate) (Executor) (Administrator) (Guardian) I consent to allowance of this claim for $ __________________ as a ___________class Claim, costs to be charged to the estate. NOTE: If claim is based upon a written instrument, a copy must be attached. ______________________________________________________________________________ I ____________________________________________ that on ________________, _______ (Certify) (State on Oath) A copy if this claim was mailed by ____________________________________________ (registered mail, return receipt requested) (Ordinary mail) to __________________________________and to his/her attorney of record. (Executor) (Administrator) (Guardian) Signed and Sworn before me this ________________________, ______ _____________________________________ ___________________________________ (Attorney) (Non-Attorney) Non-Attorney statement must be notarized (Notary Public) NOTE: Unless the legal representative or his/her attorney waives mailing & delivery, or consents to the allowance of the claim, a copy of the claim MUST be mailed or delivered the legal representative AND to his/her attorney. If the claim is against the estate or a decedent and is filed on or before the claim date, the copy may be mailed by ordinary mail. If the copy is mailed after the claim date, of if the claim is against the estate of a disabled person, the mailing MUST be by registered mail return receipt requested. 171P-21a Rev.10/00 2002 © American LegalNet, Inc.