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w GO -+ N v 7 = r CO W OT V 4:.� s('-' y` a) ,. .:7,-: .S.i ' cl > -I Z 0 Return to: Duane A. Burns, Attorney, P.O. Box 2300, Grand Island, NE 68802 I 60.nv REVOCABLE TRANSFER ON DEATH DEED NOTICE TO OWNER: You should carefully read all information on the other side of this form. You May want to Consult a Lawyer Before Using This Form. If you are married and both spouses do not sign this deed, the deed may be void. WARNING: The property transferred remains subject to inheritance taxation in Nebraska to the same extent as if owned by the transferor at death. Failure to timely pay inheritance taxes is subject to interest and penalties as provided by law. WARNING: The designated beneficiaries are personally liable, to the extent of the value of the property transferred, to account for Medicaid reimbursement to the extent necessary to discharge any such claim remaining after application of the assets of the transferor's estate. The designated beneficiaries may also be personally liable, to the extent of the value of the property, for claims against the estate, statutory allowances to the transferor's surviving spouse and children, and the expenses of administration to the extent needed to pay such amounts by the personal representative. WARNING: The Department of Health and Human Services may require revocation of this deed in order to qualify for Medicaid assistance. This form must be recorded before your death, or it will not be effective. IDENTIFYING INFORMATION Owner Making This Deed: Kathryn B. Layher, single 312 West 12th Street Wood River, NE 68883 LEGAL DESCRIPTION OF THE PROPERTY Lot Seven (7), in Block "A", First Addition to the Town of Wood River, Hall County, Nebraska. PRIMARY BENEFICIARIES I designate the following beneficiaries if at least one of the beneficiaries survives me: Dale Layher and Francis Becker. 1