HomeMy WebLinkAbout09-19-13 AFFIDAVTP OF DISCLAIMEIt OB INTERE5T BY ROGER E.HOLEN
REGISTET2 Q�WII.LS OF (;IIMBERLANI}COUN"fY,PENNSYL'VANIA
Name of Decedcnt: Taylor lcan Bolen
Date af Death: June 34,2012 File Number: 2012-00'T74
To the Register:
' I, Roger E. Bolen, srveaz npon my aath oz affirm under P����S'af P�7�Y.that to the best
af miy knowledge,infarmation and belief:
i l. Taylor 3ean Bolen{"DecedenY'}died on 7une 30,2012. I am a lega!heir encUor have been
€ named as a beneficiary af the e.state of the dr.cedtaz.
i
i ' 2. I am the adult fathes of t6e decedent and may have a prescnt ar praspective inzerest in the
f ! estate af ihe deceder►t.
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! 3. I hcreby disclaiaz any and a11 interest in the estate af the decedent, including any pmce�eds of
Ilitigaflon doc&eted ta i:13-CV-t0U3 in the United 5tates District Court for the Middle District of
i PennsyIvania.
� I agree to defend.indemnify and hold al!other heirs aadfor beneficiaries harmless from
' any�laims,deanands,fees ar expenses that result in any way from daeir zeliance upan tl i,s;:.;
; Aflidavit.
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i DA'i"Et}at �,z� r �+�+�1 ,�rti ,on this�day of 20�.
et sfate � � `` � ,
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i, A�FFIAN'T': � u> ',,,.
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Signaiure: "/( r�.r.ti ��„� ��?-t=C.+tJ r
' (sign,futi tegat name »presence of notmy publtc) � .'
I Naxne{please pri»t): �a t.�,j"�,_,�°��n7� ���'R? �''
IAddress: �"7 G? t�i[=5 z=��2.11 t a j.�. 1'zc�
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I SUSSCRIS�17 AND SWORN TO C3R AFFIRMED UPON PIIVALTY OF PERJUItY before
�mc,this 1�7 �y of_s���( �20�
0 MONW LTM CiF PEI4N"YLVANIA
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NEMBER PENNSY/YANtA ASiIX:1I.ti{�QF ryIYSpRtE4
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