Record Owner: ____________________ Prior Volume and Page: _____________ STATE OF OHIO COUNTY OF GEAUGA AFFIDAVIT FOR LOT SPLIT __________________________________, being first duly sworn, deposes and says: (Grantee) 1) I am presenting an instrument of conveyance from ________________________ ______________________ to ___________________________________________ for real property located in ________________, Tract _________, Lot or Section No. ____________, which was executed the ______ day of _______________, ______. 2) This conveyance is exempt from the provisions of Chapter 711 of the Revised Code for the following reason: _____ The division or partition of land is into parcels of more than twenty acres and does not involve any new street(s) or easement(s) of access. _____ The division or partition is a sale or exchange of parcels between adjoining lot owners and such sale or exchange does not create additional building sites. _____ The improvement is a private street(s) serving an industrial structure(s). (See attached legal description) 3) That I understand that this conveyance must comply with current applicable _____________________________ zoning requirements. (Township or Village) ________________________________________ Signature of Affiant (Grantee) Address: ________________________________ ________________________________________ Sworn to and subscribed before me this ______ day of _______________, _______. ___________________________________ Notary Public Prepared by: __________________________ Address: _____________________________ _____________________________________ Rev 9/2000 American LegalNet, Inc. www.FormsWorkflow.com