Small Estate Affidavit Form

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AN AFFIDAVIT TO JESSE WHITE, THE SECRETARY OF THE STATE OF ILLINOIS, PURSUANT TO 755 ILCS 5/ART. XXV OF
THE PROBATE ACT, ILLINOIS COMPILED STATUTES, AS AMENDED BY PUBLIC ACT 9 8 - 0 836 (EFF. 1-1-15).
STATE OF ILLINOIS
COUNTY OF ________________________
SMALL ESTATE AFFIDAVIT
I,
(name of affiant), on oath state:
1.
(a) My post office address is:
(b) My residence address is:_______________________________________________________________________________; and
(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:
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) ___________________________________
(Judicial Circuit) Illinois is recognized by Illinois law as my agent for 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 his/her 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 in value and consists of the following (list each asset and its fair market value):
Including vehicle(s) described below:
Make of Vehicle
Body Type
Year Model
Vehicle Identification Number
Make of Vehicle
Body Type
Year Model
Vehicle Identification Number
Last licensed in the State of Illinois in (Year) __________ License Plate Number(s)_______________________________________________
7.
Mark (X) either (a) or (b): (a)
All the decedent's funeral expenses and other debts have been paid, or (b)
All the decedent's known
unpaid debts are listed and classified as follows:
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:
Name
Post Office Address________________________________________________________Amount $_______________________________
Class 2: Surviving spouse’s award or child’s award, if applicable:
Name
Post Office Address________________________________________________________Amount $_______________________________
Class 3: Debts due the United States:
Name
Post Office Address________________________________________________________Amount $_______________________________

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