THIS IS AN ARBITRATION CASE IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS Plaintiff vs CASE NO: Defendant AFFIDAVIT OF DAMAGES The undersigned being first duly sworn upon oath, desposes and states that (he) (she) is a party to the above entitled cause of action seeking money damages or collection of taxes and states that this cause of action does not exceed $50,000.00. does exceed $50,000.00. (Signature) Signed and sworn before me , 20 (Notary Public) Attorney Name ARDC # Firm Name Attorney for Address City and Zip Telephone ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY American LegalNet, Inc. www.FormsWorkFlow.com AR 12 (Revised 12/16)