Fill and Sign the Name Street Address City State Ampampamp Zip Code Title Order No Form

RECORDING REQUESTED BY: AND, WHEN RECORDED, MAIL DOCUMENT TO:Name: Street Address: City, State & Zip: [Official Use Only] AFFIDAVIT OF DEATH OF JOINT TENANT STATE OF } SS COUNTY OF }BEFORE ME, the undersigned Notary Public, personally appeared, , “Affiant”, who upon being duly sworn, deposes and states upon his or her oath or affirmation, the following: 1.My name is and I reside at . 2.I owned real property as a joint tenant with , such real property located in County, State of , described as follows: See Legal Description Attached as Exhibit A incorporated by reference as though set forth in full Legal Description: Title deed is recorded in Book , Page in the office of the circuit clerk of County, Arkansas.3. , my joint tenant identified above, departed this life on , 20 . A copy of the death certificate of is attached. 4.On the date of the death of , the above described real estate was owned by and , as joint tenants and the joint tenancy had not been severed by any act of the parties or by operation of law.5.Affiant is the sole surviving joint tenant of the property described above.Dated this the day of , 20 . Signature of Affiant Type of Print Name State of Arkansas County of __________________On this the ______ day of ___________, 20______, before me, ________________________, the undersigned officer, personally appeared ________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he executed the same for the purposes therein contained.In witness whereof, I hereunto set my hand and official seal.Notary Public, State of __________________My commission expires: Type or Print Name SWORN TO AND SUBSCRIBED before me this the _______ day of ______________, 20_______. __________________________ NOTARY PUBLIC My Commission Expires: ___________________