Fill and Sign the Individual to Three Individuals with Contingent Beneficiary Form

Transfer on Death Designation Affidavit Page 1 of 3 TRANSFER ON DEATH DESIGNATION AFFIDAVIT[Individual to Three Individuals with Contingent Beneficiary] STATE of OHIO ) COUNTY of ) , owner, a married individual, currently owner of record of the following real property located at , , Ohio as recorded at Volume , Page , of the County deed records: See Legal Description Attached as Exhibit A incorporated by reference as though set forth in full Legal Description: hereby designates the following as “Transfer on Death” Beneficiaries to receive the owner’s title to that property, as tenants in common, upon the death of the owner: , whose street address is , in the City of , State of , (Zip); , whose street address is , in the City of , State of , (Zip); and , whose street address is , in the City of , State of , (Zip). If any of the designated TOD Beneficiaries precede the Owner in death, then (choose one) Transfer on Death Designation Affidavit Page 2 of 3 a. the transfer to the deceased Transfer on Death Beneficiary shall become null and void and the entire property shall pass to the surviving Transfer on Death Beneficiary(ies), OR b. ________________________ shall be substituted as the Alternative Transfer on Death Beneficiary in place of the deceased Transfer on Death Beneficiary. The property shall be divided between the Transfer on Death Beneficiary(ies) that survive the owner. If all of the designated Transfer on Death Beneficiaries, and the contingent beneficiary, fail to survive the owner, this Deed shall be null and void. The above is intended to convey property known as: . Parcel # Alt Id# Prior Instrument Reference: I, wife husband of the grantor, release all rights of dower in the above described premises. WITNESS Grantor’s hand this the ____ day of ________________, 20____. Signed, Sealed and Delivered in the presence of: Witness Signature Type or Print Name Type or Print Name WitnessSignature of Spouse (if required) Type or Print Name Type or Print Name 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 Transfer on Death Designation Affidavit Page 3 of 3 Grantor’s Address: First Grantee’s Address: Second Grantee’s Address: Third Grantee’s Address: This Instrument was prepared by and return to: Signature Print or Type Name Exhibit A EXHIBIT A