(Top 3 inches reserved for recording data) AFFIDAVIT BY AN INITIAL TRANSFEREE by Individual Minn. Stat. 523.11 subd. 4 (1984) State of Minnesota, County of Minnesota Uniform Conveyancing Blanks Form 100.2.3 (2011) , being first duly sworn, on oath says: 1. Affiant is an initial transferee named in that deed dated (month/day/year) , and filed for record on (or in Book Registrar of Titles of of County, Minnesota, , as Attorney-in-Fact for , as Grantor and Principal, County, Minnesota, legally described as follows: , as Document Number (month/day/year) Page from ), in the Office of the County Recorder (check the applicable boxes) relating to real property in Check here if all or part of the described real property is Registered (Torrens) 2. Affiant 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 100.2.3 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