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k' 0 e, 4-' a i N y A3 pc k 8 0 ,„, Primary Beneficiary: rn eNz REVOCABLE TRANSFER ON DEATH DEED After recording, return to: JD Sitz, Esq., 1700 Farnam St, Ste 1500, Omaha, NE 68102 Page 1 of 2 TRANSFEROR: Marilyn B. Wiese, also known as Marilyn R. Wiese, also known as Marilyn Robb Wiese, a single person, of 104 N 1s St, Doniphan, NE 68832. Before the death of Transferor, she has the right to revoke this deed. The following real estate is transferred and conveyed by this document, effective at the death of the Transferor to the Primary Beneficiary or to the Alternate Beneficiary as provided below. South 50 feet of Lot 1, the South 50 feet of the East 40 feet of Lot 2, and the North 25 feet of the East 1/3 of Lot 8, all in Block 6 in the Original Town of Doniphan, Hall County, Nebraska The Beneficiary, takes the property subject to all conveyances, encumbrances. assignments, contracts, mortgages. liens, and other interests to which the property is subject at the Transferor's death. I designate the following beneficiary of this Revocable Transfer on Death Deed if she survives me by 120 hours: Karen D. Bohl, Trustee of the Marilyn B. Wiese Trust, or the successor trustee of the Marilyn B. Wiese Trust, of 220 E 52 St, Kearney, NE 68847 STATUTORY 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. STATUTORY WARNING: 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. STATUTORY 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. WARNING: A transfer on death deed may be set aside if the witnesses to its signing by the Transferor are not disinterested witnesses. A Disinterested witness to a 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; N) CD Cl) CD V 0) O � u