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Njosorommaimm <br />( S ) MMENMEN <br />N <br />Return to: enise Myers <br />P.O. Box 505 <br />Cairo, NE 68824 <br />rn = <br />c n s <br />n z <br />n v <br />N <br />:x, <br />AFFIDAVIT OF MARITAL STATUS <br />STATE OF NEBRASKA ) <br />)ss. <br />COUNTY OF HALL ) <br />CD <br />S <br />cri <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: Mervin R. Moeller <br />Date of Death: November 2, 2010 <br />Domicile at Death: Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Frances E. Moeller <br />Date of Marriage: November 26, 1950 <br />2. The Affiant is the daughter of the Decedent's and, in that capacity, is familiar with <br />the 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 was held by the Decedent and the <br />surviving spouse in joint tenancy, to -wit: <br />Lot Seven (7), West Lawn Addition to the City of Grand Island, Hall County, <br />Nebraska. <br />5. As of the date of death, the real estate had a fair market value of $84,994. <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 sworn to before me this AO day of February, 2018. <br />GENERAL NOTARY- State of Nebraska <br />DENISE D. MYERS <br />My Comm. Exp. Nov. 20, 2018 <br />cr )14diaik <br />ril een C. McMillan <br />Jfx/1-4 <br />Notary Public <br />\� <br />