PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE ESTATE OF , DECEASED CASE NO. CERTIFICATE OF TRANSFER NO. [Check one of the following] Decedent died intestate. Decedent died testate. Decedent died on owning the real estate described in this certificate. The persons to whom such real estate passed by devise, descent or election are as follows: Name Residence Address Transferee's share of decedent's interest [Complete if applicable] The real estate 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 monetary share which is part of the surviving spouse's total intestate share. Page 1 of 2 FORM 12.1 - CERTIFICATE OF TRANSFER 10/01/98 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. The legal description of decedent's interest in the real property subject to this certificate is: [use extra sheets, if necessary]. Prior Instrument Reference: Parcel No: This instrument was prepared by ISSUANCE This Certificate of Transfer is issued this day of , . William R. Zimmerman, Probate Judge AUTHENTICATION I certify that the above document is a true copy of the original Certificate of Transfer No. issued on and kept by me as custodian of the official records of this Court. Date William R. Zimmerman, Probate Judge By: Deputy Clerk Page 2 of 2 FORM 12.1 - CERTIFICATE OF TRANSFER American LegalNet, Inc. www.FormsWorkflow.com