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Return to: Denise Myers, Attorney P.O. Box 505 Cairo, NE 68824 Notice to Owner: Survivorship Required: This TOD Deed is Revocable: Before my death, I have the right to revoke this deed. Growing Crops: If this land is agricultural land the growing crops shall pass to: REVOCABLE TRANSFER ON DEATH DEED c:r C7 C1"1 - You should carefully read all information on this form. You may want to consult a Lawyer before using this Form. If you are married and both spouses do not sign this deed, the deed may be void. This form must be recorded with the Register of Deeds of the County in which the property is located before your death and it also must be recorded with the Register of Deeds of the County in which the property is located within 30 days after it was signed. If either of these requirements is not met, this form will not be effective. Identifying Information about Owner: Names of Owner: Mailing Address of Owner: Raymond E. Micek and 2532 Jay Street Mary H. Micek Grand Island, NE 68803 Notice to Register of Deeds: This is a transfer on death deed and Form 521 is not required with the filing of this Transfer on Death deed under Neb. Rev. Stat. §76- 214(2)(b). Legal Description: The following real estate is transferred by this document, effective at the death of the Owners to the Primary Beneficiaries or to the appropriate Alternate Beneficiary as provided below. Lot Four (4), Block Five (5), in Jenkinson Subdivision in the City of Grand Island, Hall County, Nebraska. Primary Beneficiary: We designate the following beneficiaries of this revocable transfer on death deed if the beneficiaries survive the survivor of us. Name of Primary Beneficiaries: Mailing Address of Primary Beneficiaries: Lori A. Maret 2900 W. Claire Ave., Lincoln, NE 68523 Christine M. Luther 1607 W. 16'" Street, Kearney, NE 68846 Kimberly S. Oates 2300 S.W. 47 St., Lincoln, NE 68522 David R. Micek 3700 N. Marshfield Ave., Apt. 3, Chicago, IL 60613 Transfer on Death: At the death of the survivor of us, we transfer our interest in the described property to the beneficiaries as designated above, as tenants in common. The transfer occurs at the death of the survivor of the Transferors. Under Nebraska Law, the interest of a designated beneficiary is contingent on the designated beneficiary surviving the transferor by one hundred twenty (120) hours.