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STATE OF NEBRASKA ) <br />COUNTY OF LANCASTER ) <br />2014. <br />NCLE 535 <br />c <br />0 (o <br />N <br />0 1 �� OQ SY <br />AFFIDAVIT OF MARITAL STATUS <br />ss. <br />r� n <br />rH <br />tr) <br />COMES NOW, the undersigned, being duly sworn, deposes and says that the undersigned <br />knows the Decedent and the surviving spouse of the Decedent and that the following information is <br />true and correct: <br />1. Name of Decedent: Harold O. Nielsen <br />Date of Death: April 22, 2009 <br />Domicile at Date of Death: 4136 Mason Avenue, Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Dianna J. Nielsen <br />Date of Marriage: September 6, 1969 <br />2. The Affiant is related to the Decedent as follows: Spouse <br />3. There is no Federal Estate Tax, Nebraska Inheritance Tax or Nebraska Estate Tax due. <br />4. Title to the following described real estate is held by the Decedent and the surviving spouse <br />of the Decedent in joint tenancy, to -wit: <br />Please see attached. <br />5. As of date of death, the real estate has a tax assessed value of $479,548.00 <br />6. The Decedent and Affiant were married as of date of death. There is no Nebraska <br />Inheritance Tax lien by reason of Nebraska Revised Statutes §77 -2003. There is no Nebraska <br />estate tax lien by reason of Nebraska Revised Statutes §77 -2102. <br />FURTHER Affiant sayeth naught. <br />Dianna J. Nielsen, Affiant <br />SUBSCRIBED AND SWORN to before me this "_aO day of 3 <br />NOTARY PUBLIC <br />GENERAL NOTARY - State of Nebraska <br />STACIA HEISER <br />My Comm. Exp. June 22, 2016 <br />it <br />Page 1 of 2 <br />N <br />N <br />