AFFIDAVIT OF HEIRSHIP

State of ________ }
County of ______ }ss:

________________________ , being duly sworn, deposes and says:

That (he)(she) is the (husband)(wife)(child) of ____________________ , deceased, who acquired title to premises in County, New York, described as follows:

That said ___________________ died a resident of the County of ____________ , State of ________________ , on the ______ day of ________ , 19____ seized of said premises, (testate)(intestate), and no proceedings were had in the estate, leaving surviving as (his)(her) only lawful distributees, the following named persons:

NAME             ADDRESS            RELATIONSHIP

That said decedent left (him) (her) surviving no (husband)(wife), and no child or children, (legitimate or illegitimate), no adopted child or children, no descendants of any deceased child or children, no descendants of any deceased adopted child or children, no father or mother, no brothers or sisters, no issue of any deceased brothers or sisters, no grandparents, no uncle, no aunt, and no issue of a deceased uncle or aunt other than those above named.

That all of the persons above named are of full age, except:

That all of the persons above named are of sound mind, except:

That said deceased in his/her lifetime was a citizen of the United States or a subject of __________________ .

This affidavit is made to induce First American Title Insurance Company of New York to issue its policy of title insurance covering the above premises knowing that it relies upon the truth hereof.

______________________________

Sworn to before me this day
of ________ 19 ____

____________________________
Notary Public