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Return to: Denise Myers <br />P.O. Box 505 <br />Cairo, NE 68824 <br />AFFIDAVIT OF MARITAL STATUS <br />STATE OF NEBRASKA ) <br />COUNTY OF HALL ) <br />ss. <br />COMES NOW, the undersigned, being first duly sworn upon oath, and deposes <br />and states that the undersigned knows the Decedent and the surviving spouse of the <br />Decedent and that the following information is true and correct. <br />1. Name of Decedent: Harvey E. Zichek <br />Date of Death: May 14, 2009 <br />Domicile at Death: Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Deloris L. Zichek <br />Date of Marriage: August 14, 1950 <br />2. The Affiant is the attorney for the Decedent's spouse and, in that capacity, is <br />familiar with the marital status and the death of the Decedent. <br />3. That there is no federal estate tax, Nebraska inheritance tax or Nebraska <br />estate 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 />Lot One (1), Bluhm Second Subdivision, Hall County, Nebraska <br />5. As of the date of death, the real estate had a fair market value of $110,458.00. <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 />FURTHER Affiant saith not. <br />Denise D. Myers <br />Subscribed and sworn to before me this 3 C3 ` day of mca.raN , 2022. <br />GENERAL. NOTARY - State of Nebraska <br />SUSAN R. MRKVICKA <br />_ My Comm. E. Jame 8, 2025 <br />\C\c-fes.c.ck,--Th <br />Notary Public <br />