Small Estate Affidavit Form - Circuit Court Of Cook County, Illinois

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Small Estate Affidavit
(04/28/15) CCP N608 A
(To be used only when decedent died on or after September 4, 1991)
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/Zip Code _____________________________________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 Cook County, 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.
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. (Attach a list of each asset, e.g. cash,
stock and its fair market value.)*
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 7(a) or 7(b).
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 administra-
tion; and statutory custodial claims as follows:
Name and Post Office Address
Class 2: the surviving spouse’s award or child’s award, if applicable, as follows:
Name and Post Office Address
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