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213w c. nCD z m z. co Return to: Jamie Mues Jankovitz 03 202 W. 3rd St. Grand Island, NE 68801 AFFIDAVIT OF MARITAL STATUS WITH DEATH CERTIFICATE 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. 1. Name of Decedent: James P. Thomas Date of Death: April 8, 2021 Domicile at Death: Hall County, Nebraska Name of Surviving Spouse: Sally S. Thomas Date of Marriage: December 29, 2006 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: Part of the South Half (S1/2) of Section Eleven (11), Township Eleven (11) North, Range Nine (9) West of the Sixth P.M., Hall County, Nebraska, described as follows: Commencing at the Southwest corner of Lot Three (3), of Voss Subdivision of part of the South Half (S1/2) of said Section Eleven, thence running East along and upon the South section line of said Section Eleven, for a distance of 538 feet; running thence North at right angles to said South Section line, a distance of 259.0 feet, running thence East and parallel to said South Section line, a distance of 100 feet; running thence South and at right angles to said South Section line, a distance of 259.0 feet to said South Section line; and running thence West along and upon said South Section line a distance of 100 feet to the point of beginning. (Physical Address: 3102 E. Seedling Mile Rd., Grand Island, NE) 5. As of the date of death, the real estate had an assessed value of $112,230.00. 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. t 1 4*110, OA at .4__I Sally S. omas, A fiant STATE OF NEBRASKA ) ) ss: COUNTY OF HALL ) SUBSCRIBED and sworn to before me on this Q.20 day of ')I a c,� , 2021 by Sally S. Thomas, Affiant. 0' GENERAL NOTARY - State of Nebraska JAMIE MUES JANKOVITZ Ms My Comm. Exp. May 25, 2022 PREPARED BY: Jamie Mues Jankovitz, #20754 BRADLEY LAW OFFICE, PC 202 West Third Street Grand Island, NE 68801 Telephone: (308) 382-2128 Notary Public