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STATE OF OHIO COUNTY OF GEAUGA , Name Address AFFIDAVIT OF CONFIRMATION ORC 5302.222 being first duly sworn deposes and says: 1) That (name and address) and (name and address) is/are surviving designated transfer on death beneficiary(ies) of property under a duly recorded transfer on death beneficiary affidavit. 2) Other designated transfer on death beneficiaries who did not survive the Grantor is/are: ; a certified copy of his/her/their death certificate(s) are attached hereto; 3) Said property is known as , Geauga County, State of Ohio, and is further described as permanent parcel # on the records of the Geauga County Auditor. A full legal description of said property is stated in the transfer on death affidavit which is recorded in the records of the Geauga County Recorder in Volume , Page , and a copy of the legal description which is attached hereto*. (If beneficiary is a trustee, attach copy of trustee affidavit.) 4) That the Grantor, about hereto. 5) That by virtue of the death of the party listed in Item #4 above, those listed in Item #1, above, is/are the fee simple owner(s) of the above described property. *Excepting ,2 , at died on or , ; and a certified death certificate is attached Sworn to and subscribed before me this day of , Notary Public Rev Dec-10 American LegalNet, Inc. www.FormsWorkFlow.com