STATE OF OHIO,
COUNTY OF FAIRFIELD, SS:

	_____________________________, being duly sworn, says that (she-he) is the
surviving spouse of ___________________________who died (testate-intestate) on 
______________________: that the said ________________, deceased, at the time of
h__ death, was the owner of the following described (*boat-*motor):

        Year_________________Boat__________Boat No_______________Model____________
Motor____________ Mtr. no.______________ Ohio Certificate of Title no_____________
*Complete Section (A)
      (A) That the approximate value of the boat/motor is $______. Affiant further
says that under Sec. 2106.19 ORC, (she-he) as the surviving spouse of
_________________________________, deceased, is entitled to receive "ONE" boat/motor
from the estate of h__ deceased spouse which is not an asset of the estate but is
subject to Estate Tax Determination. That the above described boat/motor has not
been disposed of by the Will of ____________________, deceased; and no other
vehicle of said decedent has been transferred to this surviving spouse pursuant to
Sec. 2106.19 ORC.
   
   

					___________________________________________
					      Surviving Spouse Signature

Sworn to before me and subscribed in my presence by the said_______________________,
this ________________ day of __________________, 19___.

                         
                          SEAL                   _________________________________
						 Notary, Clerk, Deputy Clerk