Recorded at the Request Of s1

Recorded at the Request of:

When Recorded, mail to:

Order No: Affidavit Terminating Joint Tenancy

I, , residing at ,being duly sworn on oath do depose and say:

That affiant is the surviving joint tenant of who died on or about , at and who was a resident of the state of

That at the time of death, said decendent was the owner in joint tenancy with this affiant of the following described property:

The deed vesting title was recorded in Docket at page ;

That the deceased was one and the same person named in that certain Death Certificate, a certified copy of which is attached hereto and made a part hereof;

That all property and estate of decedent, wheresoever located, at the time of death, did not exceed the value of $______and

Further, that there is no Estate Tax due, either Federal or State, on the estate of said deceased.

Dated:______

State of County of }ss.

Subscribed, sworn to and acknowledged before me this _____ day of ______, 19_____, by

Notary Public My Commission Expires: