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Owner Making This Deed: Charlotte J. Rerucha, single a /k/a Charlotte P. Rerucha 706 Joehnck Drive Grand Island, NE 68801 me: Pamela S. Bengston 1026 West Nobes Road York, NE 68467 equally, as tenants in common. IDENTIFYING INFORMATION REVOCABLE TRANSFER ON DEATH DEED Return to: Duane A. Burns, Attorney, P.O. Box 2300, Grand Island NE 68802 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 by a transferor, a transferor's spouse, or both a transferor and the transferor's spouse in order to qualify or remain qualified for Medicaid assistance. LEGAL DESCRIPTION OF THE PROPERTY Lot Seven (7), Block Two (2), in Pleasant View Addition, an Addition to the City of Grand Island, Hall County, Nebraska. PRIMARY BENEFICIARIES I designate the following beneficiaries if at least one of the beneficiaries survives Christopher L. Rerucha #10 Sonja Drive Doniphan, NE 68832