735 ILCS 5/25-1 ­ Payment or delivery of small estate of decedent upon affidavit ­ (a) When any person, corporation, or financial institution (1) indebted to or holding personal estate of a decedent, (2) controlling the right of access to decedent's safe deposit box or (3) acting as registrar or transfer agent of any evidence of interest, indebtedness, property or right is furnished with a Small Estate Affidavit in substantially the form hereinafter set forth, that person, corporation, or financial institution 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 the affidavit or to an agent appointed as hereinafter set forth. STATE OF ILLINOIS COUNTY OF McHENRY SMALL ESTATE AFFIDAVIT ($100,000 and under) I, ________________________________________________________________________, on oath state: (Name of Affiant) 1. (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: ________________________________________ 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 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. 3. The decedent's name is_______________________________________________________________________ The date of the decedent's death was __________________________________, 20______, and I have attached a copy of the death certificate hereto. The decedent's place of residence immediately before his death was____________________________________ 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; 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. (Here, list each asset, e.g. cash, stock and its fair market value); (a) All of the decedent's funeral expenses and other debts, have been paid, OR (b) All of the decedent's known unpaid debts are listed and classified as follows (include the name, post office address and amount): Strike either 7(a) or 7(b) Class 1: funeral and burial expenses, which include reasonable amounts paid for a burial space, crypt, or niche; a marker on the burial space; and care of the burial space, crypt, or niche; expenses of administration; and statutory custodial claims as follows: Name and Post Office Address Amount 4. 5. 6. 7. Class 2: the surviving spouse's award or child's award, if applicable, as follows: Name and Post Office Address PR-AFF2: Revised 01/01/2015 pursuant to Public Act 98-0836 Amount Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Class 3: debts due the United States, as follows: Name and Post Office Address Amount Class 4: money due employees of the decedent of not more than $800 for each claimant for services rendered within 4 months prior to the decedent's death and expenses attending the last illness, as follows: Name and Post Office Address Amount Class 5: money and property received or held in trust by the decedent which cannot be identified or traced, as follows: Name and Post Office Address Amount Class 6: debts due the State of Illinois and any county, township, city, town, village, or school district located within Illinois, as follows: Name and Post Office Address Amount Class 7: all other claims, as follows: Name and Post Office Address Amount 7.5 I understand that all valid claims against the decedent's estate described in paragraph 7 must be paid by me from the decedent's estate before any distribution is made to any heir or legatee. I further understand that the decedent's estate should pay all claims in the order set forth above, and if the decedent's estate is insufficient to pay the claims in any one class, the claims in that class shall be paid pro rata. There is no known unpaid claimant or contested claim against the decedent, except as stated in paragraph 7. (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 8. 9. *(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 PR-AFF2: Revised 01/01/2015 pursuant to Public Act 98-0836 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 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 OR (b) The decedent left a will, which has been filed with the 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 w