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c` /6-1) 7 7'7 q This TOD Deed is Revocable Before my death, I have the right to revoke this deed. Legally Required Warnings in the TOD Deed: Please pay close attention to the following warnings: 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. 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 claim remaining after application of the assets of the transferor's estate. 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 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. Signature of owners Making This Transfer on Death Deed I, David J. Wetherilt, the transferor, sign my name to this instrument on November 10, 2015, 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 that I willingly direct another to sign for that signer, that I execute it as my free and voluntary act for the purposes therein expressed, that I am eighteen years of age or older or am not at this time a minor, and that I am of sound mind and under no constraint or undue influence. Davi• et -rilt, Transferor We, Shelly Nielsen and Lori Ready the witnesses, sign our names to this instrument, being first duly sworn, and do hereby declare to the undersigned authority that the transferors sign and execute this transfer on death deed to transfer their interest in the described real property and they sig n it willingly or either or both of them willingly directs another to sign for either or both of them, and that they execute it as their free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of the transferors, hereby signs this deed as witness to the transferors' signing, and that to the best of his or her knowledge the transferors are eighteen years of age or older or are not at this time minors and the transferors are of sound mind and under no constraint or undue influence. • e 4 0 308 N. Locust St. #308, Grand Island, NE Shelly Nielse Witness address K 308 N. Locust St. #308, Grand Island, NE Lori Re ay Witness address Page 2 Wetherilt TOD Deed 2607 West Charles St.,Grand Island,NE