____________________________________________________________ Affidavit Naming Surviving Spouse or Joint Survivor (O.R.C. 5302.17) I, _____________________________, being first duly sworn, deposes and says as follows: 1. That __________________________ and __________________________ are joint owners of property under a duly recorded survivorship or tenancy by entireties deed. 2. That the property is known as______________________________________. Situated in the ____________ of ______________, County of _____________, and State of Ohio. Known as being Parcel # _________________ Alt ID# _________________________________ The original survivorship deed is recorded in Volume_______Page___________ Reception Number______________ Registered Land________________ Revised 3/2013 American LegalNet, Inc. www.FormsWorkFlow.com 3. That _______________________ died on ______________________, and said (certified) death certificate has been issued and attached hereto. 4. That by the virtue of the death of the party listed in item #3 above __________________________________ is/are the fee simple owner(s) of the above described property and requests that this fact be reflected on the land and tax records of the County of Summit. ___________________________ Signature of Affiant ___________________________ Printed Name of Affiant STATE OF OHIO COUNTY OF SUMMIT Before me, a notary public, in and for said County, personally appeared above named _____________________________________________________________________ who acknowledge that ________did sign the foregoing instrument and that the same is ______ free act. In testimony whereof I have hereunto set my hand and official seal, this ______ day of _______________, 20____. ______________________________ Notary Public My commission expires:___________ This instrument was prepared by: ___________________________ Revised 3/2013 American LegalNet, Inc. www.FormsWorkFlow.com