State of Illinois
International Will Information Registration Form
755 ILCS 10/10
Secretary of State Index Department
111 E. Monroe
Springfield, IL 62756
217-782-7017
www.cyberdriveillinois.com
Authorized Person — Individuals who have been admitted to practice law before the courts of this state or individuals
authorized by laws of the United States including members of the diplomatic and consular service of the United States
designated by Foreign Service Regulations.
Return completed form to: Secretary of State, Index Department, 111 E. Monroe, Springfield, IL 62756 • 217-782-7017
A file stamped copy will be returned as your receipt.
(Please print or type.)
1. Name of Individual:
_____________________________________________________________________________________
2. Social Security Number:
_____________________________________________________________________________________
3. Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. Date and Place of Birth:
_____________________________________________________________________________________
_____________________________________________________________________________________
5. Intended Place of Deposit or Safekeeping of the Instrument Pending Death of the Maker:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I declare that the above information is true and correct:
______________________________________________________________________
Printed by authority of the State of Illinois. December 2009 — 50 — I 217
Signature of Authorized Person
