Fill and Sign the Survivorship Affidavit Form

SURVIVORSHIP AFFIDAVIT STATE OF ___________________________ ) ) SS: COUNTY OF       )       [insert name of person making affidavit] , being first duly sworn upon oath deposes and says: 1. That       [insert name of deceased person] (the “Decedent”) died on the       day of       , 20       at       [and insert location of death.] 2. That the Decedent and       [insert name of Decedent’s spouse] were duly and legally married at the time they acquired title as husband- and-wife to the following described real estate: Legal Description:       3. That the marital relationship which existed between them at the time they acquire title to said real estate remained in effect and unbroken until the date of the decedent's death. 4. That all funeral expenses in connection with the death of the Decedent have been paid in full. 5. That all of the assets of the Decedent which would be includable for Federal State Tax purposes, including joint bank accounts and life insurance on the Decedent's life were not sufficient to necessitate payment of Federal Estate Tax. Further affiant sayeth not. Signature of Affiant       Type or Print Name STATE OF ____________________ ) ) SS: ACKNOWLEDGMENT COUNTY OF       ) Before me, a Notary Public in and for said County and State, personally appeared       who acknowledged the execution of the foregoing instrument, and who, having been duly sworn, stated that any representations therein contained are true. Survivorship Affidavit Page 1 of 2 Witness my hand and Notary Seal this       day of       , 20       . Resident of       County, _______ Signature My Commission Expires: Printed       I affirm, under penalties for perjury, that I have taken reasonable care to read that each Social Security number in this document, unless required by law. Name This instrument prepared by:       Survivorship Affidavit Page 2 of 2