Tom Orlando Lorain County Clerk of Court of Common Pleas SURVIVING SPOUSE AFFIDAVIT WATERCRAFT O.R.C 2106.19 IN THE MATTER OF (DECEASED): STATE OF OHIO LORAIN COUNTY ) ) ) SS Title Division , being first duly cautioned and sworn, says that (he/she) is the surviving spouse of, who died on and that the (boat/outboard motor) owned by the decedent described herein (have/has) not otherwise been disposed of by will and that no other (boat/outboard motor) of the decedent have been transferred pursuant to sec. 2106.19 O.R.C. The estimated appraised value of the (boat/outboard motor) is $ Surviving spouse may elect only one boat and one outboard motor (2106.19 O.R.C.) (Attach copy of proof of death) Description of watercraft being transferred: Year: _________ Make: ____________________________________________ Model: _________________________ WIN: _______________________________________________ HP: _________ Feet: _________ Inches: _________ Number of inboard motors contained on the boat: ________ Identification number of the first inboard motor: _________________________________________________________ Year: __________ Make: ___________________________ Model: ___________________________ HP: __________ Identification number of the second inboard motor: ______________________________________________________ Year: __________ Make: ___________________________ Model: ___________________________ HP: __________ Previous title number: ________________________________ (Submitted with this Affidavit) Name and Address of lienholder: ______________________________________________________________________ __________________________________________________________________________________________________ (If none, please state. Please submit a copy of the security agreement) Name and Address on affiant: _____________________________ Sworn to and subscribed in my presence this _____ of ____________, 20 _____ ______________________________________________ Clerk, Deputy Clerk, Notary public, Attorney at Law _____________________________________________ _____________________________________________ Signature of Affiant American LegalNet, Inc. www.FormsWorkFlow.com