State of Illinois
Deposit of Wills and Certification of Diligent Search
15 ILCS 305/5.15
Secretary of State Index Department
111 E. Monroe
Springfield, IL 62756
217-782-7017
www.cyberdriveillinois.com
*TESTATOR:
__________________________________________________
* Last Name, First Name, Middle Initial
__________________________________________________
* Last Known Address
__________________________________________________
* City, State, ZIP
__________________________________________________
Alternate Name(s)
__________________________________________________
Alternate Name(s)
________________________ ________________________
Birthdate Social Security Number
(last four digits)
*DEPOSITOR:
__________________________________________________
* Last Name, First Name
__________________________________________________
Company or Firm (if applicable)
__________________________________________________
* Address
__________________________________________________
* City, State, ZIP
__________________________________________________
* Telephone Number
(Please type or print.)
OFFICE USE ONLY * DATE OF DEPOSIT:
* FEE PAID:
____________________
*DESCRIPTION OF DOCUMENT(S) DEPOSITED:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
*Number of Pages ____________________________________ *Date of Execution (if known)______________________________
*CERTIFICATION OF DILIGENT SEARCH: (Provide details of the steps taken for diligent search.)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth
in this instrument are true and correct, except as to matters therein stated to be on the information and belief and as to such matters the
undersigned certifies as aforesaid that he verily believes the same to be true.
______________________________________________________________________________________ _____________________
* Signature of Depositor * Date
*Required by Law
Printed by authority of the State of Illinois. December 2009 — 25 — I 225
