Small Estate Affidavit {DEK-SEA}

Page 1 of 5 Small Estate Affidavit Rev. 05-27-15 Reviewed: 08-30-18 IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS SMALL ESTATE AFFIDAVIT I, , Affiant, on oath state: 1. (a) My post office address is: City: State: Zip (b) My residence address is: City: State: Zip: (c) My telephone number is: (d) I understand that, 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: Telephone: 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 County (of the Judicial Circuit), Illinois is recognized by Illinois law as my agent for service of process. 2. The decedent222s name is 3. The date of the decedent222s death was , and I have attached a copy of the decedent222s death certificate hereto. 4. The decedent222s place of residence immediately before death was: 5. No letters of office are now outstanding on the decedent222s estate and no petition for letters is contemplated or pending in Illinois or in any other jurisdiction, to my knowledge. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 Small Estate Affidavit Rev. 05-27-15 Reviewed: 08-30-18 6. The gross value of the decedent222s 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. (Here, list each asset, e.g. cash, stock, and its fair market value.) 7. (a) All of the decedent222s funeral expenses and other debts have been, or (b) All of the decedent222s known unpaid debts are listed and classified as follows (include the name, post office address, and 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: 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205. Class 2: the surviving spouse222s award or child222s award, if applicable, as follows: 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205. Class 3: debts due the United States, as follows: 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205. Class 4: money due employees of the decedent of not more than $800 for each claimant for services rendered within 4 months prior to the decedent222s death and expenses attending the last illness, as follows: 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205. Class 5: money and property received or held in trust by the decedent which cannot be identified or traced, as follows: 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205.. Class 6: debts due the State of Illinois and any county, township, city, town, village, or school district located within Illinois, as follows: 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205.. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 Small Estate Affidavit Rev. 05-27-15 Reviewed: 08-30-18 Class 7: all other claims, as follows: 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205. (Strike either 7(a) or 7(b)). 7.5. I understand that all valid claims against the decedent222s estate described in paragraph 7 must be paid by me from the decedent222s estate before any distribution is made to any heir or legatee. I further understand that the decedent222s estate should pay all claims in the order set forth above, and if the decedent222s estate is insufficient to pay the claims in any one case, the claims in that class shall be paid pro rata. 8. There is no known unpaid claimant or contested claim against the decedent, except as stated in Paragraph 7. 9. (a) The names and places of residence of any surviving spouse, minor children and dependent* children of the decedent are as follows: Name and Relationship Place of Residence Age of Minor Child *(Note: an adult dependent child is one who is unable to maintain himself 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 decedent222s death. If any such child did not reside with the surviving spouse at the time of the decedent222s death, so indicate). (c) If there is no surviving spouse, the award allowable to 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 decedent222s heirs, and the portion of the estate to which each heir is entitled under the law where decedent died intestate are as follows: American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 5 Small Estate Affidavit Rev. 05-27-15 Reviewed: 08-30-18 Name, Relationship and Place of Residence Age of Minor Portion of 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 decedent222s last will and was signed by the decedent and the attesting witnesses as required by law and would be admittable to probate. The names and places of residents of the legatees and the portion of the estate, if any, to which each legatee is entitled are as follows: Name, Relationship and Place of Residence Age of Minor Portion of Estate (Strike either 10(a) or 10(b). (c) Affiant is unaware of any dispute or potential conflict as to the heirship or will of the decedent. 10.3 My relationship to the decedent or the decedent222s estate is as follows: 10.5 I understand that the decedent222s estate must be distributed first to satisfy claims against the decedent222s estate as set forth in paragraph 7.5 of this affidavit before any distribution is made to any heir or legatee. By signing this affidavit, I agree to indemnify and hold harmless all creditors of the decedent222s estate, the decedent222s heirs and legatees, and other persons, corporations, or financial institutions relying upon this affidavit who incur any loss because of reliance on this affidavit, up to the amount lost because of any act or omission by me. I further understand that any person, corporation, or financial institution recovering under this indemnification provision shall be entitled to reasonable attorney222s fees and the expenses of recovery. American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5 Small Estate Affidavit Rev. 05-27-15 Reviewed: 08-30-18 11. After payment by me from the decedent222s estate of all debts and expenses listed in paragraph 7, any remaining property described in paragraph 6 of this affidavit should be distributed as follows: Name Specific sum or property to be distributed. The foregoing statement is made under the penalties of perjury. * Date Signature of Affiant Subscribed and sworn to before me, a Notary Public this day of , 20. (Notary Public Seal) Signature of Notary Public *(NOTE: A FRAUDULENT STATEMENT MADE UNDER THE PENALTIES OF PERJURY IS PERJURY, AS DEFINED IN SECTION 32-2 OF THE CRIMINAL CODE OF 2012.) American LegalNet, Inc. www.FormsWorkFlow.com