I, (name of affiant) , on oath state:
NAME..........................
ADDRESS.......................
CITY..........................
TELEPHONE (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 ...... (County) (Judicial Circuit) Illinois is recognized by Illinois law as my agent for service of process.
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:
........................................................
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)).
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.)
Name, relationship and place of residence | Age of minor OR | Portion of Estate |
Name, relationship and place of residence | Age of minor | Portion of Estate |
(Strike either 10(a) or 10(b)).
I understand that the decedent's estate must be distributed first to satisfy claims against the decedent's 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 decedent's estate, the decedent's 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 attorney's fees and the expenses of recovery.
Name Specific sum or property to be distributed
The foregoing statement is made under the penalties of perjury*.
.........................
Signature of Affiant
Signed and sworn before me on (insert date).
.........................
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.)
755 ILCS 5/25-1