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C <br />T <br />N ,, F <br />W ..` / 7 <br />0 <br />rC ✓` <br />/� r— <br />\ %s <br />COUNTY OF HALL <br />STATE OF NEBRASKA <br />) ss. <br />GENERAL NOTARY - State of Nebraska <br />It . GALEN E. STEHLIK <br />My Comm. Exp. May 1, 2014 <br />�. • <br />AFFIDAVIT OF MARITAL STATUS <br />C1l cn <br />(1) <br />COMES NOW, the undersigned, being duly sworn, deposes and says that the undersigned is the <br />surviving spouse of the Decedent and that the following information is true and correct: <br />1. Name of Decedent: Kenneth W. Fladseth <br />Date of Death: October 15, 2012 <br />Domicile at Date of Death: Hall County, Nebraska <br />Name of Surviving Spouse: Janice M. Fladseth <br />Date of Marriage: May 24, 1980 <br />2. The Affiant is related to the Decedent as follows: surviving spouse. <br />3. There is no Federal Estate Tax, Nebraska Inheritance Tax or Nebraska Estate Tax that is due because <br />of Decedent's death. <br />4. Title to the following described real estate is held by the Decedent and the surviving spouse of the <br />Decedent in joint tenancy, to- wit: <br />Lot Six (6), Block Thirty -Nine (39), Russel Wheeler's Addition to <br />Grand Island, Hall County, Nebraska <br />5. As of the date of death, the real estate has a fair market value of $60,136.00. <br />6. The Decedent and Affiant were married as of date of death. There is no Nebraska Inheritance Tax <br />lien by reason of Nebraska Revised Statutes Section 77 -2003. There is no Nebraska estate tax lien by reason <br />of Nebraska Revised Statutes Section 77 -2102. <br />FURTHER AFFIANT SAITH NOT. <br />Jaliice M. Fladseth <br />SUBSCRIBED and SWORN to before me this . 'day of , 2012, <br />RO°=) <br />