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~. ~ a1° n ~; ~ ~: ~ ~ ~~ c, m ~ c n = ~ ~ --~ ~ ~ rv ~.. ~..... ~ ~ ~ n~ ~ L~? ~ r ~ © ~ r Z CT1 ~ ~ © ~ r ~ ~ ~ cD CO ~I ~ ~ ~,,,,, fU cn ~ C.!"1 ~ - ~- C1J rll "'"~ ~ C7] Ln CL7 Z ~ ~ _ AFFI AVIT F T ~ ~ STAT _ ~~~~~~ ~~ Comes Now, the undersigned, being first duly sworn upon oath , deposes and states that the %~p- DO undersigned knows the Decedent and the surviving spouse of the Dece dent and that the following information is true and correct. 1. Name of Decedent: James Hollowell Date of Death: May 15, 201.0 Domicile at Death: 1116 S. Greenwich Name of Surviving Spouse: Mary J. Hollowell fka: Mary J. Russell Date of Marriage: June 10, 1978 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: (SEE ATTACHED LEGAL DESCRIPTION: EXHIBIT "A" ) 5. As of the date of death., the real estate had a fair market value of $55,549.00 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. Mar J. 11 ell fka: Mary J. Russell, Affiant STATE OF NEBRASKA ) ss: COUNTY OF HALL ) _ SUBSCRIBED and sworn to before me on this c~ day of , 2010, by Mary Hollowell, Affiant. ~IAINOTARV-sated Nebr~ka ~~ ~»~ rawa. ._~~ Notary Public PREPARED BY: Jamie Mues Jankovitz # 20'754 BRADLEY, ELSBERND, ANDERSEN, KNEALE & MUES JANKOVITZ, P.C. 202 West Third Street P.O. Box 639 Grand Island, NE 68802 Telephone: (308) 382-2128