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AFFIDAVIT <br />Prepared By: Timothy S. Ellsworth, 3632 South 23rd Street, Omaha, NE 68108 <br />Send Tax Statements to: Rosanne Christensen 79983 Ridge Road Walbach, NE 68882 <br />I, Timothy S. Ellsworth, being under oath and duly sworn state as follows: <br />CO <br />"D 711 <br />O <br />c: <br />1. I am the attorney representing WILLIAM J. GROSSART and PAULINE GROSSART in <br />their application with the Nebraska Department of Health and Human Services for Medicaid <br />assistance along with their daughter, ROSANNE CHRISTENSEN, who filed the application and <br />is acting on her parents behalf in seeking this Medicaid assistance; <br />2. In the past I have worked with WILLIAM J. GROSSART and PAULINE GROSSART on <br />estate planning matters and I am familiar with their estate planning documents; <br />3. Under the WILLIAM J. GROSSART and PAULINE GROSSART Revocable Trust <br />established by them as Seniors and co- Trustees and dated August 26, 2002 (hereinafter referred <br />to as the "Trust ") each are given as Trustees the power to handle real estate matters including but <br />not limited to the sale of real estate; <br />4. WILLIAM J. GROSSART has dementia and is unable to handle his personal affairs as <br />determined by his family physician, Dr. Jennifer Brown of Grand Island; and in accordance with <br />the terms of the Trust PAULINE GROSSART is currently acting as sole Trustee and has full <br />power to convey real estate by her acting alone as Trust under the terms of the Trust: <br />5. The Nebraska Department of Health and Human Services has requested that the residence of <br />the Grantor's located at 2316 W. 10 Street; Grand Island, NE 68803 and more particularly <br />described as: Lot Twelve (12) in Block Four (4) in Dill and Huston's Addition to the city of <br />Grand Island, Hall County, Nebraska be conveyed from the Trust to WILLIAM J. GROSSART <br />and PAULINE GROSSART, as husband and wife; <br />1 <br />