CIRCUIT COURT OF THE FOUR TEENTH JUDICIAL CIRCUIT ROCK ISLAND COUNTY, ILLINOIS ESTATE OF ____________________________________ No.______________ Deceased ESTATE CLAIM-TORT 1. Claimant, ________________________________ of __________________________ (name) (address) _________________________________, has a claim for $________________against (city, state, zip) this estate. 2. The nature of the claim is: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Date:__________________ _____________________ ______________ (Month, day, year) ________________________________________________________________________ AFFIDAVIT ___________________________ on oath states that the allegations in this claim are true. Signed and sworn to before me_____________________________, 20____. (SEAL) _____________________________________ Notary Public _______________________________________________________________________ Name:___________________________________ Attorney for Claimant:______________________ Address: _________________________________ ________________________________________ Telephone:_______________________________ American LegalNet, Inc. www.USCourtForms.com>>>> 2 APPEARANCE-WAIVER OF SERVICE-CONSENT I, ___________________________of the Estate of ________________________, deceased, hereby enter my appearance in the matter of the within claim, waive service of process and consent to the allowance of it for the sum of $__________ as of the Seventh Class. Date:________________________ ______________________________ _______ Signature of Representative or his Attorney ________________________________________________________________________ ____________________________________ PROOF OF SERVICE The undersigned has this day delivered or mailed a true copy of this claim (by ordinary mail) (by registered mail, return receipt attached) together with a true copy of each written instrument upon which the claim is predicated to the legal representative of the estate and to his attorney of record. Date:___________________ ______________________ _____________ Claimant By_________________________________ Subscribed and sworn to before me this _____ day of _______________, 20____. (SEAL) ________________________ _ Notary Public ________________________________________________________________________ ____________________________________ ALLOWANCE OF CLAIM This claim allowed by Court in the sum of $______________as of Seventh Class. Date:_______________________ ENTER:______________________ _______ JUDGE SEE DOCKET ENTRY REVISED 7/18/05 American LegalNet, Inc. www.USCourtForms.com