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WARNING: The designated beneficiary is 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 claims remaining after application of the assets of the Grantors' estates. The designated beneficiary may also be personally liable, to the extent of the value of the property transferred, for claims against the estate, statutory allowances to the Grantor'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 by a Grantor, a Grantor's spouse, or both a Grantor and a Grantor's spouse in order to qualify or remain qualified for medicaid assistance. I, Susan C. Roe, Grantor, sign my name to this instrument this 11 day of February, 2014, 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 described real property and that I sign it willingly or willingly direct another to sign for me, that I execute it as a free and voluntary act for the purposes therein expressed, that I am eighteen (18) years of age or older or are not at this time a minor, and that I am of sound mind and under no constrain or undue influence. Susan C. Roe, Grantor I We, F v.U �(, •Celt - and 0111 h n �� / , he witnesses, sign our names to this instrument, being first duly sw and do hereby declare to the undersigned authority that the Grantor signs and executes this transfer on death deed to transfer her interest in the described real property and that she signs it willingly or willingly directs another to sign for her, and that she executes it as a free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of the Grantor, hereby signs this deed as witness to the Grantor's signing, and that to the best of his/her knowledge the Grantor is eighteen (18) years of age or older or is no at this time a minor and the Grantor is of sound mind and under no const aint or undue • flu:+ ce. Ana% t(, ec u4 , Witness STATE OF NEBRASKA COUNTY OF DOUGLAS Subscribed, sworn to, and acknowledged before me by Susan C. Roe, the Grantor, and su`cribed and sworn to before me by PnAht. 6t.. C,(fu+Irk-- and , witnesses, this 11 day of February, 2014. (SEAL) ) ss. GENERAL NOTARY - State of Nebraska ALEXANDER J. WOLF My Comm. Exp. Oct 19, 2014 4820- 0196- 7639.1 0411141A C ktf J , 1__ Notary Public 201400945 Return recorded Deed to: Alexander J. Wolf, Attorney Koley Jessen, P.C., L.L.O. 1125 South 103rd Street, Suite 800 Omaha, NE 68124