Fill and Sign the Ohio Transfer Form

      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 Affidavit of Confirmation Page 1 of 3 the date of the property owner’s death: 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 Affidavit of Confirmation Page 2 of 3       Type or Print Name This Instrument was prepared by and return to:                         Signature       Print or Type Name Affidavit of Confirmation Page 3 of 3 EXHIBIT A       Affidavit of Confirmation Exhibit A