The affidavit must be substantially in the form set forth in 755 Ill. Comp. Stat.
5/25-1(b):
“I (name of affiant), on oath state:
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a.
The affiant’s address, which may include:
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•
My post office address is: _____;
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My residence address is: _____; and
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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:
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.
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b.
The decedent's name is _____;
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c.
The date of the decedent's death was _____; and I have attached a copy of the death
certificate hereto;
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d.
The decedent's place of residence immediately before his death was ______;
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e.
No letters of office are now outstanding on the decedent's estate and no petition
for letters is contemplated or pending in Illinois or any other jurisdiction, to my
knowledge;
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f.
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);
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g.
Statement regarding funeral expenses that:
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1.
All of the decedent’s funeral expenses have been paid, or
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2.
The amount of the decedent’s unpaid funeral expenses and the name and post office
address of each person entitled thereto are as follows:
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Name and post office address
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NOTE: Strike either g(1) or g(2).
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h.
There is no knowledge of an unpaid claimant or contested claim against the decedent,
except as stated in paragraph g.
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i.
Information for survivors:
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1.
The names and places of residence of any surviving spouse, minor children and adult
dependent* children of the decedent are as follows:
*Note: An adult dependent child is one who is unable to maintain himself or herself
and is likely to become a public charge.
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2.
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).
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3.
If there is no surviving spouse, the award allowable to the minor children and adult
dependent children 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),
to be divided among them in equal shares.
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j.
Statement regarding a will:
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1.
The decedent left no will
The names, places of residence and relationships of the decedent’s heirs, and the
portion of the estate to which each heir is entitled under the law where decedent
died intestate are as follows:
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2.
The decedent left a will that is filed with the clerk of an appropriate court. A certified
copy of the will on file is attached to the affidavit. To the best of my knowledge
and belief, the will on file is the decedent’s last will and was signed by the decedent
and the attesting witnesses as required by law and would be admittable to probate.
The names and places of residence of the legatees and the portion of the estate, if
any, to which each legatee is entitled are as follows:
Strike either j(1) or j(2).
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3.
Affiant is unaware of any dispute or potential conflict as to the heirship or will
of the decedent.
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k.
The property described in paragraph f. of this affidavit should be distributed as
follows:
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Specific sum or property to be distributed
Make the foregoing statement under the penalties of perjury*.
...............................
Signature of Affiant
*(Note: A fraudulent statement made under the penalties of perjury is perjury, as
defined in Section 32-2 of the Criminal Code of 2012.)