COURT OF COMMON PLEAS MONTGOMERY COUNTY, OHIO 41 North Perry Street, P.O. Box 972, Dayton, Ohio 45422 GREGORY A. BRUSH Clerk of Courts In the matter of the Estate of_________________________________, deceased. AFFIDAVIT OF SURVIVING SPOUSE FOR TRANSFER OF AUTOMOBILE OR TRUCK. ORC 4505.10 STATE OF OHIO, COUNTY OF MONTGOMERY, SS: _________________________________, being duly sworn, says that (she-he) is the surviving spouse of______________________________who died (testate-intestate) on________________ ; that the said_______________________, deceased, at the time of h__ death, was the owner of the following described (*automobile-*truck): Year____________Body Type___________Make___________Model___________ VIN________________________________Ohio Certificate of Title No.____________________ *Complete (A) or (B) below: (A) That the approximate value of the automobile is $______________. Affiant further says that under Sec. 2113.532 ORC, (she-he) as the surviving spouse of___________________________, deceased, is entitled to receive "ONE" automobile from the estate of h__ deceased spouse which is not an asset of the estate but is subject to Estate Tax Determination. That the above described automobile has not been disposed of by Will of _____________________, deceased; and no other vehicle of said decedent has been transferred to this surviving spouse pursuant to Sec. 2113.532 ORC. (B) That the approximate value of the truck is $______________. Affiant further says that the decedent did not own an automobile, that the above described truck was used as a method of conveyance by the decedent during h__ lifetime and/or by the decedent's family. Affiant further says that under Sec. 2113.532 ORC, (she-he) as the surviving spouse of___________________, deceased, is entitled to receive the above described truck from the estate of h__ deceased spouse which is not an asset of the estate but is subject to Estate Tax Determination. That the above described truck has not been disposed of by Will of_____________________________, deceased; and that no other vehicle of said decedent has been transferred to this surviving spouse pursuant to Sec. 2113.532 ORC. ___________________________________ Surviving Spouse Signature Sworn to before me and subscribed in my presence by the said_________________________. this______________day of_______________, 20__. ________________________________ SEAL Notary, Clerk, Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com