Affidavit to Obtain Payment or Delivery of the Assets of a Decedent Whose Estate Does Not Exceed One Hundred Thousand Dollars 755 ILCS 5/25-1 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 WILL 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 12th Judicial Circuit, Will County, Illinois is recognized by Illinois law as my agent for the service of process. 2) The decedent's name is _______________________________________________________________. 3) The date of the decedent's death was ____________________, and I have attached a copy of the death certificate hereto. 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 either 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 ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 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: _____________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ (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). (SEE REVERSE SIDE) 29C (page 1 of 4) (Revised 03/15) American LegalNet, Inc. www.FormsWorkFlow.com 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 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: ________________________________________________________