ORDER NO.	 
APN NO.	
PROPERTY ADDRESS:______________________________________

The undersigned Beneficiary hereby completes this Affidavit of Beneficiary  to Revocable Transfer on Death Deed ("Affidavit") in connection with the above referenced order number with the understanding that title and/or escrow agent, _________________, and its title insurer, Stewart Title Guaranty Company, (collectively "Title Company") will be relying upon this Affidavit if Title Company elects to close the above order or  issue title insurance, and that additional signed pages will be attached if necessary to be able to provide complete responses. 
The undersigned Beneficiary, each for himself and/or herself to the best of his/her knowledge, declare as follows:
1.	_______________ (“Transferor”) executed that certain Revocable Transfer on Death Deed (“TODD") in favor of _________________ (whether one or more “Beneficiary”) recorded ____________ as Instrument No. _______ of Official Records of __________ County, which was recorded on or before 60 days after the TODD was signed and notarized.
2.	The undersigned Beneficiary is not aware of any other Revocable Transfer on Death Deed having been executed by the Transferor.
3.	The description of the Property in the TODD falls within the definition of real property defined in Chapter 293, Part 4 Revocable Transfer on Death Deed (effective 2016), as either  (1) real property improved with not less than one nor more than four residential dwelling units; or (2) a condominium unit; or (3) a single tract of agricultural real estate of 40 acres or less that is improved with a single family residence.

4.	The TODD Transferor was of sound mind and had the capacity to enter into a contract when the TODD was signed before a notary public.

5.	The undersigned Beneficiary has no knowledge of Transferor's revocation of the TODD.

6.	The undersigned Beneficiary has not, and will not, disclaim the transfer of the Property to the Beneficiary under the TODD.

7.	The undersigned Beneficiary has no knowledge of (i) any party contesting the enforceability or validity of the TODD or transfer of the Property upon the death of the Transferor; or (ii) any notice of action (Lis Pendens) being recorded against the Property; or (iii) any lawsuits or claims against the Property.

8.	The undersigned Beneficiary: (Check the appropriate item with an "X")

( ) Is/Are the only known heir(s) of the Transferor.
( ) Is/Are aware of the following heirs of the Transferor:
      (include the undersigned when applicable)

9.	The Transferor is deceased and: (Check the appropriate items with an X)

( ) Evidence of Transferor's death has been recorded and proof of such recording is 
      attached herewith.
( ) Evidence of Transferor's death will be recorded; the undersigned Beneficiary will 
     complete an Affidavit of Death of Transferor Under Revocable Transfer on Death
     Deed evidencing the Transferor's death and will provide the completed document, 
     along with a death certificate, to Title Company for recording prior to closing.

( ) The change in ownership statement has been filed pursuant to R&T Code § 480 and 
 proof of such filing is attached herewith.
( ) The change in ownership statement required pursuant to R&T Code § 480 will be 
     completed and filed prior to closing.

10.	With regard to Medi-Cal benefits: (Check the appropriate item with an "X")

( ) The Transferor received Medi-Cal benefits and, pursuant to Probate Code § 215, the
      State Department, Director of Health Care Services has been notified of the Transferor’s
      death and provided a copy of the death certificate.
( ) The Transferor did not receive Medi-Cal benefits at the time of death.

11.	There are no Medi-Cal funds or amounts due and owing to the State of California.

12.	There will not be and is no estate tax due and owing.

13.	There will not be any probate or administration of the Transferor's estate.

The undersigned Beneficiary, under penalty of perjury, hereby declares and certifies that the above information is truthful and accurate and intended to be relied upon by Title Company. The undersigned Beneficiary understands that Title Company, in its sole discretion, may elect to not proceed to close and insure the above referenced matter based upon the attestations above.

Date: __________________________	     Date: ____________________________	
Beneficiary 1 — Printed Name	Beneficiary 2 — Printed Name

Beneficiary 1 — Signature
Beneficiary 2 — Signing Date

(Jurat on following page)

                                			  	

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached and not the truthfulness, accuracy, or validity of that document.

State of California 
County of ______________________

Subscribed and sworn to (or affirmed) before me on this _______ day of ____________________, 20___ by
_______________________________, personally known to me or provided to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

_______________________________________					
Notary Public Signature