Small Estate Affidavit {171P-1}

SMALL ESTATE AFFIDAVIT ($100,000 and under) I, ____________________________________________________ on oath state: (Name of Affiant) 1. (a) My post office address is: _______________________________________________________________________ (b) My residence address is: ______________________________________________________________________ (c) 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: ____________________________________ Phone (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 Lake County, 19 recognized by Illinois law as my agent for service of process.. 2. 3. The decedent's name is: _______________________________________ The date of decedent's death was _______________________________ , and I have attached a copy of the death certificate hereto. 4. The decedent's place of residence immediately before his 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. (Here, list each asset, e.g. cash, stock, and its fair market value). (Attach additional pages if necessary). Name (Type of asset) ________________________________________ ________________________________________ ________________________________________ Amount and/or Description _____________________________________________ _____________________________________________ _____________________________________________ th Judicial Circuit, Illinois is 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) 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: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Page 1 of 4 171P-1 (Rev. 1/15) American LegalNet, Inc. www.FormsWorkFlow.com Class 2: the surviving spouse's award or child's award, if applicable, as follows: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Class 3: debts due the United States, as follows: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 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 decedent's death and expenses attending the last illness, as follows: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Class 5: money and property received or held in trust by the decedent which cannot be identified or traced, as follows: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Class 6: debts due the State of Illinois and any county, township, city, town, village, or school district located within Illinois, as follows: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Class 7: all other claims, as follows: ___________________________________________________________________________________________ ___________________________________________________________________________________________ (Strike either 7(a) or 7(b)). (Attach additional pages 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 against the decedent, except as stated in paragraph 7. 9. (a) The names and places of residence of any surviving spouse, minor children and adult 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. Page 2 of 4 171P-1 (Rev.1/15) American LegalNet, Inc. www.FormsWorkFlow.com (b) The award allowable to the surviving spouse of a decedent who was an Illinois resident is $ _________________ ($20,000 plus $10,000 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