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01904710 Before my death, 1 have the right to revoke this deed. Legally Required Warnings in the TOD Deed: Please pay close attention to the following warnings. WARNING: The property transferred remains subject to inheritance taxation in the 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 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 ofadministration to the extent needed to pay such amounts by the personal representative. WARNING: The Department of health and Hunan 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 medical assistance. Signature of Owner Making this Transfer on Death Deed I, Shirley F. Wolzen, the transferor, sign my name to this instrument thi4 day of August, 2019, and being first duly sworn, do hereby declare to the undersigned authority that I sign and execute this transfer on death deed to transfer our interest in the described real property and that 1 sign it willingly or willingly direct another to sign for me, that 1 execute it as my free and voluntary act for the purposes therein expressed, that I am eighteen years of age or older and am not at this time a minor, and that 1 am of sound mind and under no constraint or under influence. S irley Izen, Transfer ► WARNING: The two witnesses must be disinterested for this Deed to be valid. An interested witness means any individual who on the date of this deed is or would be entitled to receive any interest in the land if the transferor died under circumstances existing at the date of the signing of this deed. We, /9//[50/1 J0, and 'b �,, �..� L..1, l -e - , the witnesses, sign our names to this instrument, being fully duly sworn, and do hereby declare to the undersigned authority that the transferors signed and executed this transfer on death deed to transfer their interest in the described real property and that they sign it they sign it willingly or willingly direct another to sign for them. and that they executed it as their free and voluntary act for the purpose therein expressed, and that each of us, in the presence and hearing of the transferors, hereby sign this deed as witness to the transferors signing, and that to the best of our knowledge the transferors are eighteen years of age or older or are not at this time a minor and the transferors are of sound mind and under no constraint or undue influence. d/16;;(X Witness STATE OF NEBRASKA ) ) ss. COUNTY OF HALL Witness Subscribed, sworn to, and acknowledged before me by Shirley F. Wolzen, a single person, the transferor, and subscribed and sworn to before me by flikwi l?. Sp and D tw,ne L Z l tr. r witnesses, this Lr`It' day of L, �,,�-r , 2019. i1 GENERAL NOTARY - State of Nebraska JAMIE MUES JANKOVITZ My Comm. Exp. May 25, 2022 v !� tary Public Page 2 of 2