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AFFIDAVIT OF MARITAL STATUS <br />STATE OF NEBRASKA ) <br />) ss: <br />COUNTY OF HALL ) <br />COMES NOW the undersigned, being duly sworn, deposes and <br />says that the undersigned is the surviving spouse of the Decedent <br />and that the following information is true and correct: <br />1. Name of Decedent: Barbara Jean Zoucha <br />Date of Death: August 23, 2004 <br />Domicile at Date of Death: Grand Island, Nebraska <br />Name of Surviving Spouse: Edwin Zoucha <br />Date of Marriage: August 5, 1988 <br />2. The Affiant is related to the Decedent as follows: <br />Husband. <br />3. There is no federal estate tax, Nebraska inheritance tax <br />or Nebraska estate tax due. <br />4. Title to the real estate, as set forth below, is held by <br />the Decedent and the surviving spouse of the Decedent in joint <br />tenancy: <br />THE WEST 16' OF LOT 10, ALL OF LOT 11 AND THE EAST <br />10 5/10' OF LOT 12, BLOCK 4, BLAIN ADDITION TO THE CITY <br />OF GRAND ISLAND, HALL COUNTY, NEBRASKA <br />5. As of the date of death, the real estate has a fair <br />market value of: $54,000.00. <br />6. The Decedent and Affiant were married as of the date of <br />death. There is no Nebraska inheritance tax lien by reason of <br />// -s -d <br />;0 <br />ri n <br />M <br />r pr <br />rn <br />Q <br />Cf <br />'j <br />n <br />o <br />r ��:'� <br />p <br />p> <br />a� <br />co <br />GN <br />� <br />CD <br />"t <br />3 <br />r Tye <br />O <br />4 <br />Uj <br />a <br />U) <br />co <br />N <br />") <br />` <br />o <br />CD w <br />N <br />cn <br />O <br />AFFIDAVIT OF MARITAL STATUS <br />STATE OF NEBRASKA ) <br />) ss: <br />COUNTY OF HALL ) <br />COMES NOW the undersigned, being duly sworn, deposes and <br />says that the undersigned is the surviving spouse of the Decedent <br />and that the following information is true and correct: <br />1. Name of Decedent: Barbara Jean Zoucha <br />Date of Death: August 23, 2004 <br />Domicile at Date of Death: Grand Island, Nebraska <br />Name of Surviving Spouse: Edwin Zoucha <br />Date of Marriage: August 5, 1988 <br />2. The Affiant is related to the Decedent as follows: <br />Husband. <br />3. There is no federal estate tax, Nebraska inheritance tax <br />or Nebraska estate tax due. <br />4. Title to the real estate, as set forth below, is held by <br />the Decedent and the surviving spouse of the Decedent in joint <br />tenancy: <br />THE WEST 16' OF LOT 10, ALL OF LOT 11 AND THE EAST <br />10 5/10' OF LOT 12, BLOCK 4, BLAIN ADDITION TO THE CITY <br />OF GRAND ISLAND, HALL COUNTY, NEBRASKA <br />5. As of the date of death, the real estate has a fair <br />market value of: $54,000.00. <br />6. The Decedent and Affiant were married as of the date of <br />death. There is no Nebraska inheritance tax lien by reason of <br />// -s -d <br />