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STATE OF WISCONSIN, CIRCUIT COURT,

PR-1831, 02/18 Transfer by Affidavit ($50,000 and under) (10) and , wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF wisconsin , COUNTY Register of deeds recording area IN THE MATTER OF Decedent Transfer by Affidavit ($50,000 and under) Note: Use black ink only. Name and return address parcel identification number UNDER OATH, I STATE : 1. The decedent, with date of birth and date of death , was domiciled in County, STATE of , with a mailing address of.

PR-1831, 02/18 Transfer by Affidavit ($50,000 and under) §§711.03(10) and 867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.

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