Claim Against Estate Form - Lake County, Illinois
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1IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
LAKE COUNTY, ILLINOIS
ESTATE OF
)
)
)
)
Case No. ________________________
_____________________________________________ )
)
CLAIM AGAINST ESTATE
Now comes _______________________________________, under penalties of perjury as provided under Section 1-109
of the Code of Civil Procedure, stating:
1. Claimant, _____________________________________
has a claim for $ ____________________
(Print/Type Name)
against this Estate, which is just and unpaid after allowing all just credits, deductions and set-offs.
2. The nature of the claim is as follows:
____________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________
______________________________________
Print Claimant Address
City
Zip
Claimant Signature
NOTE: If claim is based upon a written instrument, a copy must be attached.
I, _____________________________________,
Certify
State on Oath that on ____________________, 20____
a copy of this claim was mailed by
registered mail, return receipt requested
ordinary mail to
Executor
Administrator
Guardian and to ____________________________________ located at ____________________
Address
Print Name
Print
______________________________________________________________________________________________________________________
_________________________________________
Signature
Attorney
Non-Attorney
Prepared by:
Name: ____________________________________________
Attorney’s Name: ____________________________________
Address: __________________________________________
City: ______________________________ State: __________
Phone: ______________________Zip Code: _____________
Fax: ______________________________________________
ARDC #: ___________________________________________
NOTE: Unless the legal representative or his/her attorney waives mailing and delivery, or consents to the
allowance of the claim, a copy of the claim MUST be mailed or delivered to the legal representative AND to
his/her attorney. If the claim is against the estate or a decedent and is filed on or before the claim date, the copy
may be mailed by ordinary mail. If the copy is mailed after the claim date, or if the claim is against the estate of a
disabled person, the mailing MUST be by registered mail return receipt requested.
171P-21a (Rev. 12/11)
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