(b) The award allowable to the surviving spouse of a decedent who was an Illinois resident is $_________________
($10,000, plus $5,000 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 9a).
(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 $_______________ ($10,000, plus $5,000 multiplied by the number of
minor children and adult dependent children), to be divided among them in equal shares.
10. Indicate either 10a or 10b by marking (X) the correct box.
(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
(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
(c) Affiant is unaware of any dispute or potential conflict as to the heirship or will of the decedent.
11. The property described in paragraph 6 of this affidavit should be distributed as follows:
Specific Sum or Property to be Distributed
By signing this sworn affidavit, Affiant acknowledges that upon payment, delivery, transfer, access or issuance
pursuant to a properly executed affidavit, the Illinois State Treasurer’s Office is released to the same extent as if
the payment, delivery, transfer, access or issuance had been made or granted to the representative of the estate.
Affiant further acknowledges that he/she is answerable to any person having a prior right and is accountable to
any representative of the estate. The Affiant signing this small estate affidavit shall indemnify and hold harmless
all creditors and heirs of the decedent and other persons relying upon the affidavit who incur loss because of
such reliance. That indemnification shall only be up to the amount lost because of the act or omission of the
Affiant.
The foregoing statement is made under the penalties of perjury. (Note: A fraudulent statement made under the
penalties of perjury is perjury, as defined in Section 32.2 of the Criminal Code of 2012.)
_________________________________________________________ ____________________________________
Signature of Affiant Date Daytime Telephone Number
Signed and sworn to by ______________________________before me this ________day of __________________, ______
______________________________________________
Notary Public
My Commission expires _____________________
IF ADDITIONAL SPACE IS NEEDED, PLEASE ATTACH REQUESTED INFORMATION.
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