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WARNING: The Department of Health and Human Services may require revocation of this Deed by a Transferor, or the Transferor's spouse, if any, or both a Transferor and the Transferor's spouse, if an order to qualify or remain qualified for medicaid assistance. Executed , 2013. I, Ruth D. Boeka, also known as Ruth Hight Boeka, single person, the TRANSFEROR, sign my name to this instrument this ik day of ; JA„,,, 0 , 1 , 2013, and being first duly sworn, do hereby declare to the undersigned authority that I sign and execute this Transfer on Death Deed to transfer my interest in the above described real property at the time of my death all in accordance with the Act, and that I sign it willingly or willingly direct another to sign for me, that I execute it as my free and voluntary act for the purposes therein expressed, that I am eighteen years of age or older or am not at this time a minor, and that I am of sound mind and under no constraint or undue influence. Ruth D. Boeka, also known as Ruth Hight Boeka We, CO 1- ic fi 6,7 o and the witnesses, sign our names to this instrument, being first duly sworn, and do hereby declare to the undersigned authority that the Transferor signs and executes this Transfer on Death Deed to transfer his or her interest in the above described real property at the time of the Transferor's death and that he or she signs it willingly or willingly directs another to sign for him or her, and that he or she executes it as his or her free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of the Transferor, hereby signs this Transfer on Death Deed as witness to the Transferor's signing, and that to the best of his or her knowledge the Transferor is eighteen years of age or older or is not at this time a minor and the Transferor is of sound mind and under no constraint or undue influe ce. O Witness W ness 20130046;