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20/602753 <br />Primary Beneficiary: <br />I designate the following beneficiary for a 100% share of the real estate covered by this <br />revocable transfer on death deed if the beneficiary survives me. <br />Name of Primary Beneficiary Mailing Address of Primary Beneficiary <br />John W. Schroeder 3740 Norseman Ave., Grand Island, NE 68803 <br />Alternate Beneficiary: <br />If my primary beneficiary named immediately above does not survive me, I designate the <br />following named alternate beneficiary for the share of the primary beneficiary named <br />immediately above if that alternate beneficiary survives me. <br />Name of Alternate Beneficiary Mailing Address of Primary Beneficiary <br />Transfer on Death: <br />At my death, I transfer my interest in the described property to the beneficiary as <br />designated above. The transfer occurs at the death of the Transferor. <br />Survivorship Required: <br />Under Nebraska law, the interest of a designated beneficiary is contingent on the <br />designated beneficiary surviving the transferor by one hundred twenty (120) hours. <br />This TOD Deed is Revocable: <br />Before my death, I have the right to revoke this deed. <br />Legally Required Warnings in the TOD Deed: <br />Please pay close attention to the following warnings: <br />1. The property transferred remains subject to inheritance taxation in Nebraska to the <br />same extent as if owned by the transferor at death. Failure to timely pay inheritance <br />taxes is subject to interest and penalties as provided by law. <br />2. 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 <br />to discharge any such claim remaining after application of the assets of the <br />transferor's estate. The designated beneficiary may also be liable, to the extent of <br />the value of the property transferred, for claims against the estate, statutory <br />allowances to the transferor's surviving spouse and children, and the expenses of <br />administration to the extent needed to pay such amounts by the personal <br />representative. <br />3. The Department of Health and Human Services may require revocation of this deed <br />by a transferor, a transferor's spouse, or both a transferor and the transferor's spouse <br />in order to qualify or remain qualified for Medicaid assistance. <br />Page2of3 <br />