SMALL ESTATE AFFIDAVIT ($100,000 and under) 1. I, ________________________________________________________________________, on oath state: (Name of Affiant) (a) My post office address is: _____________________________________________________________ (b) My residence address is: ______________________________________________________________ (c) I understand that 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: ________________________________________ Phone: (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 Clerk of the Circuit Court of McHenry County, 22nd Judicial Circuit, Illinois is recognized by Illinois law as my agent for service of process. 2. The decedent’s name is:_______________________________________________________________________ 3. The date of the decedent’s death was __________________________________, 20______, and I have attached a copy of the death certificate hereto. 4. The decedent’s place of residence immediately before his 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) Name (Type of asset) Amount and/or Description ___________________________________________________________________________________________ ___________________________________________________________________________________________ 7. *(a) All of the decedent’s debts, including funeral expenses have been paid, or *(b) The amount of the decedent’s debts including unpaid funeral expenses, and the name and post office address of each person entitled thereto are as follows: Person: ___________________________________________________ Amount $_________________________ Person: ___________________________________________________ Amount $_________________________ *Strike either 7(a) or 7(b) PR-AFF2: Revised 12/02/2010 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 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: Name and Relationship Place of Residence Age of Minor ____________________________________________________________________________________________ ____________________________________________________________________________________________ *note: An adult dependent 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 $____________________________________ ($20,000 plus $10,000 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 a decedent who was an Illinois resident is: $____________________________________ ($20,000 plus $10,000 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 relationships of the decedent’s heirs, and the portion of the estate to which each heir is entitled under the law where decedent died intestate are as follows: Name, Relationship and Place of Residence Age of Minor Portion of Estate ____________________________________________________________________________________________ ____________________________________________________________________________________________ *(b) The decedent left a will, which has been filed with the Circuit Clerk of an 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 either 10(a) or 10(b) (c) Name, Relationship and Place of Residence Age of Minor Portion of Estate ____________________________________________________________________________________________ ____________________________________________________________________________________________ (d) Affiant is unaware of any dispute or potential conflict as to the heirship or will of decedent. PR-AFF2: Revised 12/02/2010 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 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 Prepared by: __________________________________________________________________________________ *(Note: A fraudulent statement made under the penalties of perjury is perjury, as defined in Section 32-2 of the Criminal Code of 1961.) (a) 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 10 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 10 of the affidavit; and the payment, delivery, transfer, access or issuance shall be made or granted to or on the order of the agent. (b) 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 to 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 therefor to any person having a prior right and is accountable to any representative of the estate. (c) The affiant signing the small estate affidavit prepared pursuant to subsection (b) of the 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. Such indemnification shall only be up to the amount lost because of the act or omission of the affiant. Any person recovering under this subsection shall be entitled to reasonable attorney’s fees and the expenses of recovery. (d) 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 whom the affiant names as his agent for service of process. If no such person is named or if, for any reason, service on the named person cannot be effectuated, the attorney who prepared the affidavit shall be the agent for service of process. PR-AFF2: Revised 12/02/2010 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com