IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS - IN PROBATE Estate of CASE NO: CLAIM 1. Claimant (name) against this estate. 2. The nature of the claim is* has a claim for $ Address City and State Telephone Attorney Name ARDC# Firm Name Attorney for Petitioner Address City & Zip Telephone *When the claim is based upon a written instrument, a copy of the instrument must be attached. When the claim is based on tort, so state. (SEE REVERSE SIDE) ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY 33B 12/16 American LegalNet, Inc. www.FormsWorkFlow.com No. , 20 IN THE CIRCUIT COURT OF WILL COUNTY , 20 Mailing and delivery of copy of claim waived (Representative) (Attorney for Representative) County Department - Probate Division ,20 Estate of I (certify) that on of this claim was (mailed) (delivered in person) (mailed by ordinary mail) (state of oath) , 20 a copy to Representative CLAIM and to Attorney for Representative Attorney or Agent for claimant (Agent's statement must be notarized) Claimant Amount of Claim $ Subscribed and sworn to before me this , 20 . Notary Public day of Set for hearing at m. in Room , 20 , 20 I consent to the allowance of this claim for $ as a claim of the class. Representative Attorney for Representative WILL COUNTY COURTHOUSE JOLIET, ILLINOIS 60431 Date of Letters , 20 ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY Unless the representative or his attorney waives in writing the mailing or delivery of a copy of the claim or consents in writing to the allowance of the claim, the claimant shall cause acopy of the claim to be mailed or delivered to the representative and tohis attorney of record, if any, and shall file proof of such mailing or delivery within 10 days after the filing of the claim. American LegalNet, Inc. www.FormsWorkFlow.com