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Return to: n art tv rn 2 S n Jamie Mues Jankovitz P.O. Box 639 Grand Island, NE 68802 -0639 AFFIDAVIT OF MARITAL STATUS 1. Name of Decedent: James Cemper Date of Death: December 28, 2016 Domicile at Death: Hall County, Nebraska Name of Surviving Spouse: Sharon M. Cemper Date of Marriage: October 4, 1980 GENERAL NOTARY - State of Nebraska JAMIE MUES JANKOVITZ My Comm. Exp. May 25, 2018 PREPARED BY: Jamie Mues Jankovitz, #20754 BRADLEY LAW OFFICE, PC 202 West Third Street P.O. Box 639 Grand Island, NE 68802 Telephone: (308) 382 -2128 'amiabradleylawofce.com otary Public Comes Now, the undersigned, being first duly sworn upon oath, deposes and states that the undersigned knows the Decedent and the surviving spouse of the Decedent and that the following information is true and correct. 2. The Affiant is the wife of the Decedent and in that capacity is familiar with the marital status and the death of the Decedent. 3. That there is no federal estate tax, Nebraska inheritance tax or Nebraska estate tax due. 4. Title to the following described real estate is held by the Decedent and the surviving spouse in joint tenancy, to wit: Lot One (1) in Block Two (2), Schimmer's Addition to the City of Grand Island, Hall County, Nebraska. (Physical Address: 403 W. 13`" St., Grand Island, Ne) 5. As of the date of death, the real estate had a fair market value of $104,396.00 6. The Decedent and the surviving spouse were married as of the date of death. There is no Nebraska inheritance tax lien by reason of Nebraska Revised Statute § 77 -2003. There is no Nebraska estate tax lien by reason of Nebraska Revised Statute §77 -2102. FURTHER THIS AFFIANT SAYETH NOT. Sharon M. Cemper, Affiant STATE OF NEBRASKA ) ) ss: COUNTY OF HALL ) SUBSCRIBED and sworn to before me on this /1 day of 2017 by Sharon M. Cemper, Affiant. 8