APPLICATION FOR THE T E R M I N AT I O N O F D E C E D E N T ' S I N T E R E S T A N D C O N F I R M A T I O N O F AP P L I C A N T ' S I N T E R E S T I N P R O P E R T Y DECEDENT'S NAME DATE OF DEATH ADDRESS OF DECEDENT AT DATE OF DEATH CITY ST ZIP PRESENTATION OF DEATH CERTIFICATE I c e r t i f y t h a t I h a ve vi e w e d a c e r t i f i e d c o p y o f t h e d e c e d e n t ' s d e a t h certificate. __ _ __ _ __ _ _ __ _ __ _ __ __ _ __ _ __ _ _ __ _ __ _ __ REGISTER OF DEEDS SIGNATURE __ _ __ _ __ _ __ _ _ __ DATE Recording area Name and return address: THE INTE REST OF THE DECEDENT I N THE PROP ERTY NOTED HE REIN I S H E R E B Y T E R M I N AT E D / C O N F I R M E D U N D E R T H E F O L L O W I N G S T AT U T E : (please check appropriate statute ) s . 8 6 7 . 0 4 5 wh i c h p e r t a i n s t o r e a l p r o p e r t y i n w h i c h t h e d e c e d e n t wa s a j o i n t tenant, had a vendor's or mortgagee's interest, or had a life estate. (You must provide a copy of the document establishing interest in the real property.) s. 867.046 which pertains to property of a decedent specified in a marital property agreement; survivorship marital property ; or a third party confirmation; or a nonprobate transfer on death as described in s.705. 10(1). (You must provide a copy of the document establishing interest in property.) Presentation of recorded document establishing interest in real estate. DOCUM DOCUMENT # VOLUME/REEL PAGE/IMAGE RECORDS/DEEDS Parcel Identification Number S E N D T AX S T AT E M E N T T O : Description of the real estate. See Attached Description of personal property (if any) being transferred. You may list savings accounts, checking accounts an d securities on attached pages. Indicate person(s) receiving property . D E C L AR AT I O N : I (W e ) d e c l a r e t h a t t h i s d o c u m e n t i s , t o t h e b e s t o f m y ( o u r ) k n o w l e d g e a n d b e l i e f , t r u e , c o r r e c t a n d c o m p l e t e a n d i s i n c o n f o r m i t y wi t h t h e p r o v i s i o n s a n d l i m i t a t i o n s o f t h e W i s c o n s i n S t a t u t e s . N a m e a n d Ad d r e s s Ap p l i c a n t ' s Ap p l i c a n t S i g n a t u r e (List all remaindermen/ Interest in Property Date (Notarized) beneficiaries. If more space is needed, attach pages. ) (ie: spouse, remainderman, beneficiary) (P ri nt or type nam e bel ow si gnature) T h i s d o c u m e n t wa s d r a f t e d by:(print or type name below) S T AT E O F W I S C O N S I N , C o u n t y o f S u b s c r i b e d a n d s wo r n t o b e f o r e m e o n : by the above named person(s): NOTE: SEE DIRECTIONS. Wisconsin Register of Deeds Association Form HT-110 Website Version 05/2010 Signature of Notary or other person authorized to administer an oath (as per s 706.06, 706.07) Print or type name: Title: Date Commission Expires: T H I S I S A S T AN D AR D F O R M . AN Y M O D I F I C AT I O N S T O T H I S F O R M S H O U L D B E C L E AR L Y I D E N T I F I E D . American LegalNet, Inc. www.FormsWorkFlow.com