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�� <br />�� <br />- <br />0 - <br />� �. <br />N �� <br />B �� <br />� <br />�� <br />� = <br />0 — <br />�� <br />� <br />� <br />� <br />L: <br />�A� <br />�1f � � <br />� _ <br />� <br />� + <br />i <br />� <br />.T. � <br />1�� <br />� <br />p <br />( <br />r .� � <br />� C"� (!� <br />� --1 <br />s �� "•' c v N , . � <br />n - r, z - � <br />� r*'� —I m O <br />c� r'P' � -� o �"''' - � <br />O ('V O <br />� -J ''� z N "°' <br />c''' � 'L7 � m � � <br />W <br />m 3 r' D � , � <br />r3 (!) �L <br />c� <br />� N D O7 <br />�� ' �...� ' <br />� � � O � <br />U ,� R turn To: <br />Denise D. Myers <br />STATE OF NEBRASKA ) 611 N Diers Ave. , stel <br />)SS. Grand Island, NE 68803 <br />COUNTY OF HALL ) <br />� <br />COMES NOW, the undersigned, being first duly swom upon oath, and deposes and <br />states that the undersigned knows the Decedent and the surviving spouse of the Decedent <br />and that the following information is true and correct. <br />1. Name of Decedent: Donald B. Rapien <br />Date of Death: November 23, 2011 <br />Domicile at Death: Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Sally Jean Rapien <br />Date of Marriage: September 24, 1977 <br />2. The A�ant is the son of the Decedent and, in that capacity, is familiar writh the <br />marital status and the death of the Decedent. <br />3. That there is no federal estate tax, Nebraska inheritance tax or Nebraska estate <br />tax due. <br />4. Title to the following described real estate is held by the Decedent and the <br />surviving spouse in joint tenancy, to-wit: <br />Lot Nineteen (19), West Bel Air Fifth Addition to the City of Grand Island, <br />Hall County, Nebraska. <br />5. As of the date of death, the real estate had a fair market value of $94,967.00. <br />6. The Decedent and the surviving spouse were married as of the date of death. <br />There is no Nebraska inheritance tax lien by reason of Nebraska Revised Statute §77- <br />2003. <br />FURTHER Affiant saith not. <br />Subscribed and swom to before <br />� <br />�'� day of .��a����, <br />2. <br />��,�,,,.�,,,� ary ublic <br />a. �� � <br />�Y Comm. fsD- FebraaN??.II013 <br />