IN THE CIRCUIT COURT FOR THE THIRD JUDICIAL CIRCUIT MADISON COUNTY, ILLINOIS Claimant:______________________ Address:_______________________ _______________________ In Re: The Estate of________________________, Deceased. Case #____________ Claim __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Amount of Claim ______________ ______________ ______________ ______________ ______________________________, being duly sworn, on oath says that the Estate of:______________________________, deceased, is indebted to ______________________________________, in the sum of ______________. After allowing all just credits, deduction and set offs; that the same is just and unpaid on this _______ day of _________________, 20____. That attached hereto and made a part of this affidavit is a true and correct itemized statement of said account or a true and correct copy of original promissory note, showing all endorsements thereon. ________________________________ Claimant Subscribed and sworn to before me this ________ day of ______________________, 20____. ____________________________________ (Seal) Notary Public - Clerk American LegalNet, Inc. www.FormsWorkFlow.com