NOTICE OF DEATH AFFIDAVIT AND ACCEPTANCE OF TRANSFER ON DEATH INSTRUMENT

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SEND SUBSEQUENT TAX BILL TO:
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The undersigned beneficiary or beneficiaries, being duly sworn on oath, state as follows:

That [name of owner] died on _____________ 20__, a resident of 	 	    County, Illinois, owning residential real estate legally described below:

[Legal Description- (Schedule of Real Estate Attached)]

That the street address of the residential real estate is: 	 	                                             and the parcel identification number is:   PIN 	 	 	__

That the Transfer on Death Instrument is dated

and recorded as Document No. _

_ in the

Office of the Recorder for  	  County, Illinois.

That the undersigned whose names and addresses appear below are all the beneficiaries entitled to receive under the Transfer on Death Instrument:

Address

IN WITNESS WHEREOF, the undersigned beneficiary(ies) hereby accept the transfer of residential real estate under the transfer on death instrument this  	day of 	20_.

________________________________   (Seal)

[Print Name]_____________________
_

________________________________   (Seal)

[Print Name]_____________________
STATE OF ILLINOIS	)
) ss
COUNTYOF 	)

I, the undersigned, a Notary Public in and for the said County, in the State aforesaid, DO HEREBY CERTIFY THAT [NAME OF BENEFICIARY (IES)] personally known to me to be the same person(s) whose name(s) are subscribed to the foregoing instrument, appeared before me this day in person and swore on oath to the foregoing affidavit.

Signed and sworn to before me this 	  day of
	 	 	A.D. 20	     .

Notary Public

My commission expires on 	 	 	      

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