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REVOCABLE TRANSFER ON DEATH DEED <br />NOTICE TO OWNER: <br />You should carefully read all information on this form. If you are married and both <br />spouses do not sign this deed, the deed may be void. <br />WARNING: The property transferred remains subject to inheritance taxation in <br />Nebraska to the same extent as if owned by the transferor at death. Failure to timely <br />pay inheritance taxes is subject to interest and penalties as provided by law. <br />WARNING: The designated beneficiaries are personally liable, to the extent of the <br />value of the property transferred, to account for Medicaid reimbursement to the extent <br />necessary to discharge any such claim remaining after application of the assets of the <br />transferor's estate. The designated beneficiaries may also be personally liable, to the <br />extent of the value of the property, for claims against the estate, statutory allowances to <br />the transferor's surviving spouse and children, and the expenses of administration to the <br />extent needed to pay such amounts by the personal representative. <br />WARNING: The Department of Health and Human Services may require revocation of <br />this deed in order to qualify for Medicaid assistance. This form must be recorded before <br />your death, or it will not be effective. <br />IDENTIFYING INFORMATION <br />Owner Making This Deed: <br />Andrew M. Enevoldsen <br />4612 Deva Drive <br />Grand Island, NE 68801 <br />LEGAL DESCRIPTION OF THE PROPERTY <br />Lot Two (2) in Davis Acres Third Subdivision, a subdivision, as surveyed, <br />platted and recorded, Hall County, Nebraska. <br />PRIMARY BENEFICIARIES <br />I designate the following beneficiaries, if at least one of the beneficiaries survives me. <br />Lisa A. Grauerhloz <br />1816 28th Road <br />Hildreth, Nebraska 68947 <br />Angela K. Robertson <br />221 North Rotary Drive, Unit C <br />Highpoint, NC 27262 <br />1 <br />