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� za <br />_ C ; CI S <br />N 'J z <br />0 <br />�� rnain <br />rn <br />co <br />rrl <br />rn <br />Return to: Denise Myers <br />O. Box 505 <br />V Cairo, NE 68824 <br />AFFIDAVIT OF MARITAL STATUS <br />STATE OF NEBRASKA ) <br />) ss. <br />COUNTY OF HALL ) <br />See attached Exhibit "A ". <br />FURTHER Affiant saith not. <br />GENERAL NOTARY - State of Nebraska <br />DENISE D. MYERS <br />My Comm. Exp. Nov. 20, 2018 <br />R nda Jar <br />Subscribed and sworn to before me this / day of December, 2017. <br />cn <br />Notary Public <br />COMES NOW, the undersigned, being first duly sworn 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: Emmet P. Jarzynka <br />Date of Death: November 1, 2017 <br />Domicile at Death: Cairo, Hall County, Nebraska <br />Name of Surviving Spouse: Dorothy Jarzynka <br />Date of Marriage: December 31, 1955 <br />2. The Affiant is the son of the decedent and in that capacity, is familiar with 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 />5. As of the date of death, the real estate had a fair market value of $265,044.00. <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 />