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202000664 <br />Survivorship Required <br />Under Nebraska law, the interest of a designated beneficiary is contingent on the designated beneficiary <br />surviving the transferor by one hundred twenty hours. <br />This TOD Deed is Revocable <br />Before my death, I have the right to revoke this deed. <br />Legally Required Warnings_in the TOD Deed: Please pay close attention to the following warnings. <br />Warning: <br />The property transferred remains subject to inheritance taxation in Nebraska to the same extent as if owned <br />by the transferor at death. Failure to timely pay inheritance taxes is subject to interest and penalties as <br />provided by law. <br />Warning: <br />The designated beneficiary is personally liable, to the extent of the value of the property transferred, to <br />account for Medicaid reimbursement to the extent necessary to discharge any such claim remaining after <br />application of the assets of the transferor's estate. The designated beneficiary may also be personally liable, <br />to the extent of the value of the property transferred, for claims against the estate, statutory allowances to <br />the transferor's surviving spouse and children, and the expenses of administration to the extent needed to pay <br />such amounts by the personal representative. <br />Warning: <br />The Department of Health and Human Services may require revocation of this deed by a transferor, a <br />transferor's spouse, or both a transferor and the transferor's spouse in order to qualify or remain qualified for <br />Medicaid assistance. <br />Signature of Owner Making This Transfer on Death Deed <br />I, Severiana Alvidrez, the transferor, sign my name to this instrument on January 15, 2020, and being first <br />duly sworn, do hereby declare to the undersigned authority that I sign and execute this transfer on death deed <br />to transfer my interest in the described real property and that I sign it willingly or willingly direct another <br />to sign for me, that I execute it as my free and voluntary act for the purposes therein expressed, that I am <br />eighteen years of age or older or am not at this time a minor, and that I am of sound mind and under no <br />constraint or undue influence. <br />�f enctl lw k\VcIre7) <br />Severiana Alvidrez, Owner/Transferor <br />drew) <br />We, Michaela Arndt and Deidre White, the witnesses, sign our names to this instrument, being first duly <br />sworn, and do hereby declare to the undersigned authority that the transferor signs and executes this transfer <br />on death deed to transfer his or her interest in the described real property and that he or she signs it willingly <br />or willingly directs another to sign for him or her, and that he or she executes it as his or her free and <br />voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of the <br />transferor, hereby signs this deed as witness to the transferor's signing, and that to the best of our knowledge <br />the transferor is eighteen years of age or older or is not at this time a minor and the transferor is of sound <br />mind and under no constraint or undue influence. <br />Acknowledgement <br />STATE OF NEBRASKA <br />COUNTY OF DAWSON <br />) ss. <br />M drad a <br />Witness' Name: Michaela Arndt <br />Address: 1613 Avenue C, Cozad, NE 69130 <br />u% <br />Witness' Name: Deidre White <br />Address: 106 S. Clay, Eustis, NE 69028 <br />Subscribed, sworn to, and acknowledged before me by Severiana Alvidrez, Owner/Transferor, and <br />subscribed and sworn to before me by Michaela Arndt and Deidre White, witnesses, this 15' day of January, <br />2020. <br />GENERAL NOTARY - State of Nebraska <br />CLAIRE K. BAZATA <br />My Comm. Exp. January 30, 2023 <br />S:\Deeds\Moreno, Severiana - Transfer on Death Deed.wpd <br />Notary Public <br />