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� �— � �� � a� � �� � � � ° v � '__ � � � � - � b° �� � � . b�' � � � � �� �. � � �� t � � !� 0 9 � � � Vv � STATE OF NEBRASKA COUNTY OF HALL � � � =�= e' v ! 3 '� �3 h � � ati � � � � � r ; . -- �, o �` N � ��. � ,� i-rt - � 0 v� � � . -� � �-, � �.; �, ° '� ' o o � � r., m (ti? os u� AFFIDAVIT OF MARITAL STATUS ) ss. ) c> cn O --� c � z m � � O � � 1 = rn v � r � r v� � � __.- � � c1� 0 N 0 F--� F--' O c� co ct S rD�.�� COMES NOW, the undersigned, being first duly swom upon oath, and 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: Doris Lee Bartlett Date of Death: November 27, 2010 Domicile at Death: Cairo, Hall County, Nebraska Name of Surviving Spouse: Daryl E. Bartlett Date of Marriage: May 5, 2001 2. The Affiant is the daughter 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: Lot FortySeven (47), Anderson Second Subdivision, Hall County, Nebraska. 5. As of the date of death, the real estate had a fair market value of $67,824.00. 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 Affiant saith not. �-Q� J ica Peters Subscribed and swom to before me this - day of May, 2011. �'o �'a� �.�, .��,a.ou �Z Notary Public �