Aff - Bender, Patrick_12/7/2007, F f • AFFIDAVITOFHEIRSHIP,�p,���
HEIRSHIP OF ppTRICK BENDER , DEC�ASED
STATE OF INDIANA §
�
COUNTY/PARISH OF GIB30N 6
?ROP"eRTY 01A40113
NUM6ER:.
OWNER N0. 0429025
DOC NO.
INITIALS� MDIMDF
Sh8w�1 I. Bender �•q��pN7^�� BEING OF (AWFUL AGE, AND BEING FIRS7 DULY SWORN, UPON OATH DEPOSES AND SAYS:
THAT AFFIANT IS WEII ACOUAINTEO WfTH iHE FAMILY OF THE ABOVE NAMED DECEDENT.nND WAS PERSONnLLY WELL ACOUAINTEC'MTH THE DECEDEt�! OVRINQ
DECEDEN7'S lIF'cTIM"c, HAVING KNOWN DECEOENT FOR nineteen (19� YE4RS, AND 7HAT APFIANT BEARS THE RELATIONSHIP OF
SllT'V1VIRCJ SPOUSE TO TNE DECEDENT. AFFL4NT FURTHER RFPRESENiS iHAT THE FOLLOWING SiATEhIENTS AND INFORMATION GNEN
ARE BASED UPON THE P"eRSONAL KNOWIEDGE OF THE AFFIqNT AND ARE TRUE AND CORRECT:
REfURN 4 GOGY OF
pEA1M CERTIFICAiE
Y11iF TM13 FORhf
II. PROPERTY
AT TIM: pF
Owensville
ifD DECE�ENT O\VN TME fiEAL PROGERTY OESCFI6ED W
xHIBR'A' ATTnCHED MEPEiO]
THE pEAL PROPERIY GES W IBE� W E%H19R "%:
MEFETO)
NAME OF SURVIVING SPOUSE
(If None, Ence�"NOne")
AD�RESS 8 SOCI4L SECURITY N0.
NAME OF PR�EPI`OpB� POUSE�S)
N/A
� YE3
� !:O
� YES
jj NO
Shawn I. Bender
9780 South State Road 65
Owensville, IN 47665
IF YE3. D.1TE OFACal113RION
IF YES, DAT: CF 4GOUISRiON
IN � 47665
� 9EPARF.TE GPOPEPiY
� GOMMUNMPROPEnTY
j�j SEPP{WTE PRDPERiY
�Z GOWdUNfivPROPERTY
SSN: 308-80-7344
MARRIAGE DATE OF
ENDEO 6Y DIVORCE
� DEATH
❑ DIVORCE
I] DEATH
❑ DIVORGE
'-I DEATH
DATE OF OEATH
: ;a8< Bcck 12�s7)
ENTER
N/A
BiRTH
�
MAILING ADDRESS
PARENTS'NAMES
---' ------------�-------
----------------�-t— ------
------ -------F-------
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VII. �LEASE PROVIDE BELOW, THE NAMES OF ANY SURVIVING PARENTS, BROTHERS, SISTERS AND CHILDREN OF DECE4SED BROTHERS
AND SISTERS. (Complete anly If no Surviving Spouse of Chlldren).
NAM17 RELATIONSHIP DATE OF MAILING AD�RES$ I PARENTS' NAMES
(IF NONE, ENTER `NONE') TO DECEDENT BIRTH
SIGNATURE
OF AFFIANT
MAILING
A�DRESS
CITY/STATE/
ZIP CODE
_—_ �--�—_ __
--_--_�---___—
(X . �!J.IG�'L�is'�
. r
9780 South State Road 65
Owensville, IN 47665
Subscribed and sworn to before me this 6th day of December .�4� 2�� ,.•��•...,,,
'';� °��t: +� rf,�r:,.�.
This instrumeni prepared by: -' �� '� . .'..�"
ILGI�VIV�o /1"I. � � }uJ ��r%-
William H. Bender, Attorney at Law !�l ��a��'� ��_�J�-:� '_�`' =
N0Ta4YPUBl _ `- � Y "' w ; ` ;
C'.. v� . � i `. .
17 W. Main Street, P.O. Box 430 Kathleen M. Vaughn '��';��i;,_ � ,� ,. ;
_>
Poseyville, Indiana 47633
Phone(s): 812-874-3636 or (812) 985-2102
NOTARYS PRIU�O N0.`-+E . ' •.... �'
',"� ,� � ��.::
My Commission Expires 10/09/2008 �
_ �.�,;_�_--
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EXHZBIT "A"
Propezty; Ol 940113 COLOb�IIS ShffTH
N/2 N47/9 ScC ?3, ^a3S-R14W� GIBSON COUNTY, ?NDIANA.
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