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Legally Required Warning 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. 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 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 Owner Making This Transfer on Death Deed: I, Bonita M. Dubas, the transferor(s), sign my name to this instrument o , 2017, and being first duly sworn, do hereby declare to the undersigned authority that I sign and exec this trans er on death deed to transfer my interest in the 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 of older or am not at this time a minor, and that I am of sound mind and under no constraint or undue influence. Warning: The two witnesses must be disinterested for this Deed to be valid. Interested witness means any individual who on the date that this deed is executed is or would be entitled to receive any interest in the land if the transferor died under the circumstances existing at the date of the signing of this deed. Q / �1 We, ,L6 ri /3 � and Clem /eh �Ct l FeY the witnesses, sign our names to this instrument, being first duly sworn, and do hereby declare to the undersigned authority that the transferor signs and executes this transfer on death deed to transfer his or her interest in the described real property and he or she signs it willingly or willingly directs another to sign for him or her, and that he or she executes it as their free and voluntary act for the purposes therein expressed, and the each of us, in the presence and hearing of the transferor, hereby signs this deed as a witness to the transferor's signing , and that to the best of our knowledge the transferor is eighteen years of age or older or is not at this time a minor and the transferor is of sound mind and under no constraint or undue influence. fitness Witness STATE OF NEBRASKA COUNTY OF HALL Subscribed, sworn to, and subscribed and sworn to before me witnesses, on c" Z.. GENERAL NOTARY - Mate of Nebraska DENISE D. MYERS My Comm. Exp. Nov. 20, 2018 ) ss ) Bonita M. Dubas, Transfero (o3 j j ro, /VC co firma y Address of Witness / 11 7,Ci //c ICd Address of Witness 201.704234 acknowledged))efore me by Bonita M. Duba a single peon, transferor, and by La.-1 bw11 •,q , and b Liz f32ctlaiY' , 2017. J Notary Public