Surviving Spouse Affidavit (Automobile)

Tom Orlando Lorain County Clerk of Court of Common Pleas SURVIVING SPOUSE AFFIDAVIT AUTOMOBILE O.R.C 4505.10 IN THE MATTER OF (DECEASED): STATE OF OHIO LORAIN COUNTY ) ) ) SS Title Division , being first duly cautioned and sworn, says that (he/she) is the surviving spouse of, who died on and that the automobile(s) owned by the decedent described herein (have/has) not otherwise been disposed of by will and that no other automobile(s) of the decedent have been transferred pursuant to sec. 2106.18 O.R.C. except as set out herein. The affiant further states that one of the following applies to this transaction. Check the applicable box and attach proof of death. Only one automobile as described below is being transferred and no other automobile is or will be transferred pursuant to sec. 2106.18 O.R.C. Two Automobiles are being transferred, the total value does not exceed $40,000. Description of automobile(s) being transferred: #1 Year: _______ Make: ___________________ Model: ___________________ Body Type: ___________________ VIN: ________________________________________ Previous title number: __________________________________ Name and Address of lienholder: ______________________________________________________________________ __________________________________________________________________________________________________ (If none, please state. Please submit a copy of the security agreement) Estimated appraised value for automobile #1: _____________________________________________ #2 Year: _______ Make: ___________________ Model: ____________________ Body Type: ____________________ VIN: ________________________________________ Previous title number: __________________________________ Name and Address of lienholder: ______________________________________________________________________ __________________________________________________________________________________________________ (If none, please state. Please submit a copy of the security agreement) Estimated appraised value for automobile #2: _____________________________________________ Name and Address on affiant: _____________________________ Sworn to and subscribed in my presence this _____ of ____________, 20 _____ ______________________________________________ Clerk, Deputy Clerk, Notary public, Attorney at Law American LegalNet, Inc. www.FormsWorkFlow.com _____________________________________________ _____________________________________________ Signature of Affiant