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201900566 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 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 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. This deed is revocable even if the deed or another instrument contains a contrary provision. PI, Raeford W. Lewis, the Grantor, sign my name to this instrument this (/ day of ece4„,65r4.2a18, and being first duly sworn, do hereby declare to the undersigned authority that I sign and execute this transfer on death deed to transfer my interest in the described real property and that I sign it willingly or willingly direct another to sign it for me, that I execute it as my free and voluntary act for the purposes therein expressed, that I am eighteen years of age or older or am not at this time a minor, and that I am of sound mind and under ne onstraint or u • ue) influence. Raeford " . Lewis We, kwiz,.L . and S _ ( witnesses, being disinterested and unrelateto the Grar, sign our names to this instrument, being first duly sworn, and do hereby declare to the undersigned authority that the Grantor signs and executes this transfer on death deed to transfer his interest in the described real property and that he signs it willingly or willingly directs another to sign for him, and that he executes it as his free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of the Grantor, hereby signs this deed as witness to the Grantor's signing, and that to the best of his or her knowledge the Grantor is eighteen years of age or older or is not at this time a minor and the Grantor is of sound mind and under no constraint or undue influence. i i kittt"-‘f141(14 64-4444r4 Witness Witness Ze2g4)