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£titi106Z0Z <br />Return to: <br />Galen E. Stehlik <br />fP.O. Box 400 <br />Grand Island, NE 68802-0400 <br />STATE OF NEBRASKA <br />COUNTY OF HALL <br />AFFIDAVIT OF MARITAL STATUS <br />) ss. <br />_ <br />c; <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: Darrell Robert Bolli <br />Date of Death: January 14, 2021 <br />Domicile at Date of Death: Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Lorajane Bolli <br />Date of Marriage: July 10, 1960 <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 <br />because of Decedent's death. <br />4. Title to the following described real estate is held by the Decedent and the surviving spouse of <br />the Decedent in joint tenancy, to -wit: <br />Lot Three (3), Block Two (2), West North Lawn Second Addition to the <br />City of Wood River, Hall County, Nebraska. <br />5. As of the date of death, the real estate has a fair market value of $162,752.12. <br />6. The Decedent and Affiant were married as of date of death. There is no Nebraska Inheritance <br />Tax lien by reason of Nebraska Revised Statutes Section 77-2003. There is no Nebraska estate tax lien by <br />reason of Nebraska Revised Statutes Section 77-2102. <br />FURTHER AFFIANT SAITH NOT. <br />SUBSCRIBED and SWORN to before me this fL day of February, 2021. <br />GENERAL NOTARY - State of Nebraska <br />CHERYL P. TUSTIN <br />My Comm. Exp. November 9, 2022 <br />6 <br />