COUNTY OF SANGAMON STATE OF ILLINOIS Affidavit to Obtain Payment or Delivery of the Assets of a Decedent Whose Estate Does Not Exceed One Hundred Thousand Dollars 735 ILCS 5/25-1 5/25-1. Payment or delivery of small estate of decedent upon affidavit. (a) When any person, corporation or financial corporation (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. SMALL ESTATE AFFIDAVIT I, ________________________________________________________________________________ on oath state: 1) (a) My post office address is: (b) my residence address is: (c) I understand, 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 & ZIP CODE: 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 the 7th Judicial Circuit, Sangamon County, Illinois is recognized by Illinois law as my agent for the service of process. 2) The decedent's name is ________________________________________________________________________. hereto. 3) The date of the decedent's death was ___________________ and I have attached a copy of the death certificate. 4) The decedent's place of residence immediately before 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 by intestacy or under a will, does not exceed $100,000.00 (list each asset, e.g., cash, stock and its fair market value): (attach a separate sheet, if necessary). 7) (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 (a) or (b)] NAME AND POST OFFICE ADDRESS AMOUNT Revised June 2015 Page 1 of 4 Form 69 American LegalNet, Inc. www.FormsWorkFlow.com 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, niche; expenses of administration; and statutory custodial claims as follows: (attach a separate sheet if necessary). Class 2: the surviving spouse's award or child's award, if applicable, as follows: (attach a separate sheet if necessary). Class 3: debts due to the United States, as follows: (attach a separate sheet if necessary). Class 4: money due employees of the decedent of not more than $800.00 for each claimant for services rendered within four (4) months prior to the decedent's death and expenses attending the last illness, as follows: (attach a separate sheet if necessary). Class 5: money and property received or held in trust by the decedent which cannot be identified or traced, as follows: (attach a separate sheet if necessary). Class 6: debts due to the State of Illinois and any county, township, city, town, village, or school district located within Illinois, as follows: (attach a separate sheet if necessary). Class 7: all other claims, as follows: (attach a separate sheet if necessary). 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. 8) There is no known unpaid claimant or contested claim again the decedent's, except as stated in paragraph 7. 9) (a) The names and places of residence of any surviving spouse, minor children, and adult dependent* child(ren) are as follows: NAME AND RELATIONSHIP PLACE OF RESIDENCE AGE OF MINOR CHILD Revised June 2015 Page 2 of 4 Form 69 American LegalNet, Inc. www.FormsWorkFlow.com *NOTE: An adult dependent child is one who is unable to maintain himself/herself 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 $______________ ($20,000.00 plus $10,000.00 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 $_________________ ($20,000.00 plus $10,000.00 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 the decedent died intestate are as follows: NAME, RELATIONSHIP & PLACE OF RESIDENCE - AGE OF MINOR CHILD PORTION OF THE 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 would be admitted 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: NAME, RELATIONSHIP &