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791019 201701311 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 last surviving 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 last surviving transferor's surviving spouse and children, and the expenses of the 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 We, George A. Poullos and Jody J. Poullos, husband and wife, the transferors, sign our names to this instrument on February 22, 2017 and being first duly sworn, do hereby declare to the undersigned authority that we sign and execute this transfer on death deed to transfer our interest in the described real property and that we sign it willingly or willingly direct another to sign for us, that we execute it as our free and voluntary act for the purposes therein expressed, that we are et ; teen years of age or older or are not at this time minors, and that we are of sound mind and u :1 r no constraint or undue influence. George A. Poullos Transferor J::yJ. Sul s Transferor Warning: The two witnesses must be disinterested for this Deed to be valid. An interested witness means any individual who on the date that this deed is or would be entitled to receive any interest in the land if the transferors died under the circumstances existing at the date of the signing of this deed. We, NANCY C. COENEN and CONNIE SHIRBROUN BITZES, 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 sign it willingly or willingly direct another to sign for 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 transfer on death deed as witness to the transferors' signing, and that to the best of his or her knowledge the