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Kenneth Henry Grashorn <br />3317 Shawnee Ct. <br />Grand Island, NE 68803 <br />Mary Beth Grashorn <br />3317 Shawnee Ct. <br />Grand Island, NE 68803 <br />IDENTIFYING INFORMATION <br />Owner or Owners Making This Deed: <br />. <br />- 11 <br />Cr Vs <br />G <br />co <br />REVOCABLE TRANSFER ON DEATH DEED <br />c <br />r , <br />C) <br />V <br />= n cn <br />o -4 <br />� rn <br />NOTICE TO OWNER: <br />You should carefully read all information on the other side of this form. You May want to <br />Consult a Lawyer Before Using This Form. If you are married and both spouses do not sign <br />this deed, the deed may be void. <br />WARNING: The property transferred remains subject to inheritance taxation in Nebraska to <br />the same extent as if owned by the transferor at death. Failure to timely pay inheritance taxes <br />is subject to interest and penalties as provided by law. <br />WARNING: The designated beneficiary is personally liable, to the extent of the value of the <br />property transferred, to account for Medicaid reimbursement to the extent necessary to <br />discharge any such claim remaining after application of the assets of the transferor's estate. <br />The designated beneficiary may also be personally liable, to the extent of the value of the <br />property, for claims against the estate, statutory allowances to the transferor's surviving <br />spouse and children, and the expenses of administration to the extent needed to pay such <br />amounts by the personal representative. <br />WARNING: The Department of Health and Human Services may require revocation of this <br />deed in order to qualify for Medicaid assistance. This form must be recorded before your <br />death, or it will not, be effective. <br />6,, <br />