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201907219 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. Signature of Owners Making This Transfer on Death Deed We, EARL H. BO/ERSEN and DONNA J. BOERSEN, the transferors, sign our names to this instrument on /V,' Lic / , 2019, and being first duly sworn, do hereby declare to the undersigned authority that we sign and execute this transfer on death deed to transfer our interest in the described real property and that we sign it willingly or that one or both of us willingly direct another to sign for that signer or signers, that we execute it as our free and voluntary act for the purposes therein expressed, that we are eighteen years of age or older or are not at this time a minor, and that We are of sound mind and under no constraint or undue influence. A-er t 1141, 'h EARL H. BOERSEN DONNA J. BOER Transferor Transferor Warning: The two witnesses must be disinterested for this Deed to be valid. An interested witness means any individual who on the date that this deed is or would be entitled to receive any interest in the land under this transfer on death deed if the transferor died under the circumstances existing at the date of the signing of this deed or any child, spouse or heir of that person. We, and /,46;, ;moi'/�'l , the witnesses, sign our names to this instrument, being first duly sworn, and do hereby declare to the undersigned authority that the transferors sign and execute this transfer on death deed to transfer their interest in the described real property and they sign it willingly or either or both of them willingly directs another to sign for either or both of them, and that they execute it as their free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of the transferors, hereby signs this deed as witness to the transferors' signing, and that to the best of his or her knowledge the transferors are eighteen years of age or older or are not at this time minors and the transferors are of sound mind and under no constraint or undue influence. 3io.iv,/ rs rc—d iV 6 6,6-isa( Witness' Address <3a4 /J. Coeki 4 Sir, Sd > ��•�✓�%'• �� l gdU / Witness' Address Transfer on Death Deed - Page No. 3