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201706204 <br /> WARNING: The Department of Health and Human Services may require revocation of <br /> this deed by a transferor, a transferor's spouse, or both a transferor and the transferor's <br /> spouse in order to qualify or remain qualified for medicaid assistance. <br /> Signature of Owner Making This Transfer on Death Deed <br /> I, Theresa J. O'Nele, the transferor, sign my name to this instrument on September , 2017, <br /> and being first duly sworn, do hereby declare to the undersigned authority that I sign and execute <br /> this transfer on death deed to transfer my interested in the described real property and that I sign <br /> it willingly or willingly direct another to sign for me, that I execute it as my free and voluntary <br /> act for the purposes therein expressed, that I am eighteen years of age or older or am not at this <br /> time a minor, and that I am of sound mind and under no constraint or undue influence. <br /> Theresa J. 0' f-le <br /> WARNING: The two witnesses must be disinterested for this Deed to be valid. An interested <br /> witness means any individual who on the date that this Deed is or would be entitled to receive <br /> any interest in the land if the transferor died under the circumstances existing at the date of the <br /> signing of this Deed. \n` ' <br /> We, (.f t ro ("�me / and (Y )\\ Q) V W' UlL, the <br /> witnesses, sign our names to this instrument, being first duly sworn, and do hereby declare to the <br /> undersigned authority that the transferor signs and executes this transfer on death deed to transfer <br /> his or her interest in the described real property and that he or she signs it willingly or willingly <br /> directs another to sign for him or her, and that he or she executes it as his or her free and <br /> voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing <br /> of the transferor, hereby signs this deed as witness to the transferor's signing, and that to the best <br /> of his or her knowledge the transferor is eighteen years of age or older or is not at this time a <br /> minor and the transferor is of sound mind and under no constraint or undue influence. <br /> 4- 4.1.,-- / 70i/ e�;ld <br /> Witness Name Witnes/'ddres: X56 <br /> • <br /> fitness Name Witness Address <br /> Tel -Ab <br /> Page 3 of 4 <br />