Free CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT - Illinois

CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT ROCK ISLAND COUNTY, ILLINOIS ESTATE OF ____________________________________
Deceased

No.______________

ESTATE CLAIM-TORT 1. Claimant, ________________________________ of __________________________
(name) (address)

_________________________________, has a claim for $________________against
(city, state, zip)

this estate. 2. The nature of the claim is: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Date:__________________ ___________________________________ (Month, day, year) ________________________________________________________________________ AFFIDAVIT ___________________________ on oath states that the allegations in this claim are true. Signed and sworn to before me_____________________________, 20____. (SEAL) _____________________________________
Notary Public

_______________________________________________________________________
Name:___________________________________ Attorney for Claimant:______________________ Address: _________________________________ ________________________________________ Telephone:_______________________________

APPEARANCE-WAIVER OF SERVICE-CONSENT I, ___________________________of the Estate of ________________________, deceased, hereby enter my appearance in the matter of the within claim, waive service of process and consent to the allowance of it for the sum of $__________ as of the Seventh Class. Date:________________________ _____________________________________
Signature of Representative or his Attorney ____________________________________________________________________________________________________________

PROOF OF SERVICE The undersigned has this day delivered or mailed a true copy of this claim (by ordinary mail) (by registered mail, return receipt attached) together with a true copy of each written instrument upon which the claim is predicated to the legal representative of the estate and to his attorney of record. Date:___________________ ___________________________________
Claimant

By_________________________________ Subscribed and sworn to before me this _____ day of _______________, 20____. (SEAL) _________________________
Notary Public ____________________________________________________________________________________________________________

ALLOWANCE OF CLAIM This claim allowed by Court in the sum of $______________as of Seventh Class.

Date:_______________________

ENTER:_____________________________
JUDGE

SEE DOCKET ENTRY

REVISED 7/18/05