Fill and Sign the 22 C Form

Affidavit of ConfirmationPage 1 of 3 AFFIDAVIT OF CONFIRMATION[O.R.C. 5302.22-C] STATE of OHIO ) COUNTY of ) The undersigned, being first duly cautioned and sworn, state that he/she has personal knowledge of the following information. 1. The record owner of the real property described on attached Exhibit “A” is , who died on , (deceased owner) (date of death) a certified copy of the death certificate is attached hereto as Exhibit “B”. 2. The Transfer on Death Designation Affidavit is dated and recorded at , in the Recording Office of (recording book and page) County, Ohio. 3. The following person(s), designated as Transfer on Death Beneficiary(ies) pursuant to the Transfer on Death Designation Affidavit, referred to above, survived or are in existence on the date of the property owner’s death: NAME Address FOR DEATH OF BENEFICIARY(IES) ONLY 4. The following person(s), designated as Transfer on Death Deed Beneficiary(ies) pursuant to the Transfer on Death Deed did not survive or are not in existence on the date of the property owner’s death: Affidavit of ConfirmationPage 2 of 3 NAME Address and (a) certified copy(ies) of their death certificate(s) is/are attached as Exhibit “C”. FOR CONTINGENT BENEFICIARY(IES) ONLY 5. That by virtue of the death of the party(ies) listed in item #4, the following person(s), designated as Contingent Transfer on Death Beneficiaries, survived or are in existence on the date of the property owner's death: NAME Address All records should reflect that the property described in Exhibit “A” is hereby transferred from the deceased owner to the Transfer on Death Beneficiary(ies) or Contingent Transfer on Death Beneficiary(ies). Signature of Affiant Printed name of Affiant STATE OF OHIO,} ss before me a notary public, in and for said County, County } personally appear the above named Who acknowledged that he did sign the forgoing instrument, and that the same is his free act and deed. IN TESTIMONY WHEREOF I have hereunto set my hand and official seal, at , . This day of , A.D. 20 . Notary Public Type or Print Name Affidavit of ConfirmationPage 3 of 3 This Instrument was prepared by and return to: Signature Print or Type Name Affidavit of ConfirmationExhibit A EXHIBIT A