Class 4: Money due employees of the decedent of not more than $800 for each claimant for services rendered within four (4) months prior
to the decedent’s death and expenses attending the last illness:
Name
Post Office Address________________________________________________________Amount $_______________________________
Class 5: Money and property received or held in trust by the decedent that cannot be identified or traced:
Name
Post Office Address________________________________________________________Amount $_______________________________
Class 6: Debts due the State of Illinois and any county, township, city, town, village, or school district located within Illinois:
Name
Post Office Address________________________________________________________Amount $_______________________________
Class 7: All other claims:
Name
Post Office Address________________________________________________________Amount $_______________________________
7.5 I understand that all valid claims against the decedent’s estate described in paragraph 7 must be paid by me from the decedent’s estate
before any distribution is made to any heir or legatee. I further understand that the decedent’s estate should pay all claims in the order set
forth above, and if the decedent’s estate is insufficient to pay the claims in any one class, the claims in that class shall be paid pro rata.
8. There is no known unpaid claimant or contested claim against the decedent except as stated in paragraph
7.
9. (a) The names and places of residence of any surviving spouse, minor children and adult dependent* children of the
decedent
are as
follows:
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.
)
(b) 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 in 9(a)}.
(c) 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.
10. Mark (X) either 10(a) or
10(b)
:
(a) 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:
Name,
Relationship and Place of
Residence Age of Minor Portion of Estate
(b) The decedent left a will, which has been filed with the clerk of an appropriate court. A certified copy of the will on file
is
attached.
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:
Name, Relationship and Place of Residence Age of Minor Portion of
Estate
(c) Affiant is unaware of any dispute or potential conflict as to the heirship or will of the decedent.
