PROBATE COURT OF BUTLER COUNTY, OHIO ESTATE OF CASE NO. , DECEASED CERTIFICATE OF TRANSFER NO. [Check one of the following] Decedent died intestate. Decedent died testate. Decedent died on owning the real property described in this certificate. The persons to whom such real property passed by devise, descent or election are as follows: Name Residence Address Transferee's share of decedent's interest [Com plete if applicable] The real property described in this certificate is subject to a charge of $ in favor of decedent's surviving spouse, in respect of the unpaid balance of the specific m onetary share which is part of the surviving spouse's total intestate share. FORM 12.1 - CERTIFICATE OF TRANSFER American LegalNet, Inc. www.FormsWorkFlow.com Amended: March 1, 2014 Discard all previous versions of this form CASE NO. The legal description of decedent's interest in the real property subject to this certificate is: [use extra sheets, if necessary]. Prior Instrum ent Reference: Parcel No: This instrum ent prepared by ISSUANCE This Certificate of Transfer is issued this day of , 20 . Probate Judge AUTHENTICATION I certify that this docum ent is a true copy of the original Certificate of Transfer No. issued on and kept by m e as custodian of the official records of this court. Date Probate Judge By Deputy Clerk FORM 12.1 - CERTIFICATE OF TRANSFER PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com Amended: March 1, 2014 Discard all previous versions of this form