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IDENTIFYING INFORMATION <br />Owner or Owners Making This Deed: <br />I designate the following: <br />REVOCABLE TRANSFER ON DEATH DEED <br />r %0 <br />1✓ <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 />Carole Marler <br />Legal description of the property: <br />Lot Seven (7), Block Five (5), H G Clarks Addition, Grand Island, Hall County, Nebraska <br />PRIMARY BENEFICIARY <br />m <br />-1, <br />m <br />rri <br />Q' <br />2 <br />0 <br />