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I I r r Return to: Jerom E. Janulewicz, 308 No. Locust St. Ste 306, Grand Island, NE 68801 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. Owner Making This Deed: Mary Ann Winfrey 321 North Lincoln Avenue Grand Island, NE 68801 IDENTIFYING INFORMATION LEGAL DESCRIPTION OF THE PROPERTY All of the Northerly Eighty -three and Three - tenths feet (N 83.3') of Lots Three (3) and Four (4), in Block Twelve (12), in Arnold and Abbott's Addition to the City of Grand Island, Hall County, Nebraska, as surveyed, platted and recorded. 1