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CO cw Co � TT V/ Return to: D nise Myers, Attorney V.O. Box 505 Cairo, NE 68824 Notice to Owner: Transfer on Death: Survivorship Required: rn = y ccr) CI X rt r ' - co Z rn N REVOCABLE TRANSFER ON DEATH DEED 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: X My primary or alternate beneficiary My estate I understand that if I make no choice growing crops pass to my estate. Cr) 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: Connie J. Jensen 1516 N. Lafayette (a single person) Grand Island, NE 6883 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 Owner to the Primary Beneficiary or to the appropriate Alternate Beneficiary as provided below. Lots Three (3) and Four (4), Block Two (2), Harrison's Subdivision, an Addition to the City of Grand Island, Hall County, Nebraska. Primary Beneficiary: I designate the following beneficiaries of this revocable transfer on death deed if the beneficiaries survive me: Name of Primary Beneficiaries: Mailing Address of Primary Beneficiaries: Timothy G. Jensen (undivided 1/3 interest) 821 W. 8t ", Grand Island, NE 68801 Mark A. Jensen (undivided 1/3 interest) 2115 Howard Ave., Grand Island, NE 68803 Melissa J. Ostrander (undivided 1/3 interest) 1503 Hillcrest Drive, Juniata, NE 68955 At my death !transfer my interest in the described property to the beneficiaries as designated above. The transfer occurs at my death. Under Nebraska Law, the interest of a designated beneficiary is contingent on the designated beneficiary surviving the transferor by one hundred twenty (120) hours.