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, - - 201606142 Survivorship Required Under Nebraska law,the interest of a designated beneficiary is contingent on the designated beneficiary surviving the Owner and Transferor by one hundred twenty hours. This TOD Deed is Revocable Before my death, I have the right to revoke this Deed. Legally Required Warnings in the TOD Deed: 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 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 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. 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 Owner Making This Transfer on Death Deed I, WILLIAM FLORY, the Owner and Transferor, sign my name to this instrument on September , 2016, 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 above described real property, and that I sign it willingly, 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 not at this time a minor, and that I am of sound mind and under no constraint or undue influence. / Wi'iam B. Flo Warning: The two witnesses must be disinterested for the Revocable Transfer o Death Deed to be valid. A disinterested witness to a Revocable Transfer on Death Deed means any individual who acts as a witness to a transfer on death deed at the date of its execution, and who is not a designated beneficiary or an heir, a child, or a spouse of a designated beneficiary. We, _ 4� __ and 3 ff ,E ,,,.,,..-., the witnesses, sign our names to this-'s strument, being rst duly sworn, and do hereby declare to the undersigned authority that the Transferor signed and executed this Transfer on Death Deed to transfer his interest in the above described real property, and he signs it willingly, and that he executes it as his free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of the Transferor, hereby signs this Deed as witness to the Transferor's signing, and that to the best of our knowledge the Transferor is eighteen years of age or older and is not at this time a minor and the Transferor is of sound mind and under no constraint or undue influence. 2