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Return t: V Jamie Mues Jankovitz 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: Howard William Homme aka Howard W. Homme Date of Death: January 17, 2022 Domicile at Death: Hall County, Nebraska Name of Surviving Spouse: Lorraine L. Homme Date of Marriage: June 15, 1964 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. 1/-b 4. Title to the following described real estate is held by the Decedent and the surviving spouse in joint tenancy, to wit: Lot Seventeen (17), Heritage Acres Subdivision in the City of Grand Island, Hall County, Nebraska. (Physical Address: 1 508 Spruce Rd., Grand Island, NE) 5. As of the date of death, the real estate had an assessed value of $201,981.00. 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. STATE OF NEBRASKA ) ss: COUNTY OF HALL oV a �u �vv 4-Q-PiI.0-Q> Lorraine L. Homme, Affiant SUBSCRIBED and sworn to before me on this /` 14'day of _L !_ad L,4 , 2022 by Lorraine L. Homme, Affiant. GENERAL NOTARY - State of Nebraska DIANNE C. ZILLER My Comm. Exp. July 1, 2022 PREPARED BY: Jamie Mues Jankovitz, #20754 BRADLEY LAW OFFICE, PC 202 West Third Street Grand Island, NE 68801 Telephone: (308) 382-2128 jamie@bradleylawoffice.com Page 1 of 2 otary Public