(Top 3 inches reserved for recording data) AFFIDAVIT BY AN INITIAL TRANSFEREE by Business Entity Minn. Stat. 523.11 subd. 4 (1984) State of Minnesota, County of : Minnesota Uniform Conveyancing Blanks Form 100.2.4 (2011) , being first duly sworn, on oath says: 1. Affiant is (a) (the) a initial transferee named in that deed dated (month/day/year) of under the laws of , and filed for record on (month/day/year) , , an , as Page County, Minnesota, ), in the Document Number Office of the County Recorder from relating to real property in (or in Book Registrar of Titles of of (check the applicable boxes) , as Attorney-in-Fact for , as Grantor and Principal, County, Minnesota, legally described as follows: Check here if all or part of the described real property is Registered (Torrens) 2. The above initial transferee had not received, at the time of the conveyance, a written instrument of revocation of that certain Power of Attorney dated , and filed for record on , as Document Number (month/day/year) (month/day/year) (or in Book of of Page County, Minnesota. ), in the Office of the County Recorder Registrar of Titles (check the applicable boxes) Note: Remainder of page left blank, signature page follows. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 100.2.4 Affiant (signature) Signed and sworn to before me on (month/day/year) , by (insert name of person making statement) . (Stamp) (signature of notarial officer) Title (and Rank): My commission expires: (month/day/year) THIS INSTRUMENT WAS DRAFTED BY: (insert name and address) American LegalNet, Inc. www.FormsWorkFlow.com