AN AFFIDAVIT TO JESSE WHITE, THE SECRETARY OF THE STATE OF ILLINOIS, PURSUANT TO 755 ILCS 5/ART. XXV OF
THE PROBATE ACT, ILLINOIS COMPILED STATUTES, AS AMENDED BY PUBLIC ACT 87-287 (EFF. 9/4/91).
STATE OF ILLINOIS
COUNTY OF ____________________
Small Estate Affidavit
I, _____________________________________________________________________________ (name of affiant), on oath state:
1. (a) My post office address is: _________________________________________________________________________________ ;
(b) My residence address is: ______________________________________________________________________________ ; and
(c) 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:
NAME _____________________________________________ ADDRESS _______________________________________________
CITY ______________________________________________ TELEPHONE ____________________________________________
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.
2. The decedent’s name is _______________________________________________________________________________.
3. The date of the decedent’s death was ___________________ , and I have attached a copy of the death certificate hereto.
4. The decedent’s place of residence immediately before his/her death was ___________________________________________
____________________________________________________________________________________________________________________.
5. No letters of office are now outstanding on the decedent’s estate, and no petition for letters is contemplated or pending in
Illinois or in any other jurisdiction, to my knowledge.
6. The gross value of the decedent’s entire personal estate does not exceed $100,000 in value and consists of the following:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
including a vehicle(s) described as follows:
__________________________ , _________________ , ____________ , _________________________________________________
__________________________ , _________________ , ____________ , _________________________________________________
last licensed in the State of Illinois in _______ , License Plate Number(s) _____________________________________________.
7. Mark (X) either (a) or (b): (a)
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All the decedent's funeral expenses have been paid, or (b)
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The amount of the decedent's
unpaid funeral expenses and the name and post office address of each person entitled thereto are as follows:
Name _______________________________________________ Post Office Address _____________________________________
_________________________________________________________________________________ Amount $ _______________ .
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.)
Make of Vehicle Body Type Year Model Vehicle Identification Number
Make of Vehicle Body Type Year Model Vehicle Identification Number
(Year)
Printed on recycled paper. Printed by authority of the State of Illinois. December 2008 — 6M — RT OPR 31.14
(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 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 $ _____________ ($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. Mark (X) either 10(a) or 10(b):
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(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 and Relationship Place of Residence Age of Minor Child
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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(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
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
11. Affiant is unaware of any dispute or potential conflict as to the heirship or will of the decedent.
12. The vehicle described in paragraph 6 of this affidavit should be transferred to (NAME) __________________________________ ,
(ADDRESS) ____________________________________________________________ ; this affidavit is made to induce Jesse White,
Secretary of State of Illinois, to issue a Certificate of Title to the vehicle to the assignee.
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 1961.)
___________________________________________________________________
Signature of Affiant Date
Printed on recycled paper. Printed by authority of the State of Illinois. December 2008 — 6M — RT OPR 31.14
