STATE OF OHIO COUNTY OF CUYAHOGA ) ) ) Affidavit of Surviving Spouse or Joint Survivor (R.C. 5302.17) ____________________________________________________, Being first duly sworn, deposes and Says as follows: 1) That ________________________________________________________________________________ are joint owners of property under a duly recorded survivorship or tenancy by entireties deed. That the property is known as ___________________________________________________________, _______________________ County, State of Ohio and also known as Permanent Parcel No. ___________-________-___________ in the records of the county Auditor. The original Survivorship Deed is recorded in the records of the Cuyahoga County Recorder in _____________________________________. 2) Legal Description ­ See Attached Exhibit "A" 3) 4) That _________________________________________ died on or about _______________________ at ____________________________, ________ and said death certificate has been issued and is attached hereto. That by virtue of the death of the party listed in Item # 3 above. ____________________________________________________ is the fee simple owner of the above described property and requests that this fact be reflected on the land and tax records of Cuyahoga County. ______________________________________________ Affiant SWORN TO BEFORE ME and subscribed in my presence this _______ day of ____________________________, 20_____. ______________________________________________ Notary Public Prepared by: _____________________________ American LegalNet, Inc. www.FormsWorkFlow.com