Affidavit Of Death Of Joint Tenant This Form Must Be

AFFIDAVIT OF DEATH OF JOINT TENANT This form must be completed in its entirety and signed in the presence of a Notary Public. If there is only one Surviving Joint Tenant, write “N/A” in the second space.

I / We (Surviving Joint Tenant)

, having been duly sworn, depose(s) and say(s): (Surviving Joint Tenant)

That

, the decedent mentioned in the attached Certified copy (Deceased Joint Tenant – Name on Death Certificate)

of Certificate of Death, is the same person as

, (Deceased Joint Tenant)

joint owner of account number

, (OMIF Account Number)

between

. (Names of all Joint Tenants of the OMIF Account)

That the undersigned is/are the Surviving Joint Tenant(s) and succeed(s) to all of the powers as Surviving Joint Tenant of the OMIF Account. I declare under penalty of perjury that the foregoing is true and correct.

Signature of Surviving Joint Tenant

Signature of Surviving Joint Tenant

********************************************************************************************** State of County of Subscribed and sworn to (or affirmed) before me on this day of , , by Day

Month

Year

proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me. .

Signature of Notary Public