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£8Z£00Z0Z Po nn m =D rCID x_ rn v rll= N177 TRANSFER -ON -DEATH DEED Connie J. Van Wie, a single person and resident of the State of Nebraska (hereinafter referred to as 'Transferor"), transfer upon my death and conveys and assigns to Karly J. Van Wie- Olson, an individual and resident of the State of Nebraska (hereinafter referred to as "Transferee"), all of Transferor's right, title and interest in the following described real estate and improvements thereon located in Hall County, Nebraska, to wit: All of Lots One (1) and Two (2), and all of Lot Three (3), except South Seventeen Feet (S17') thereof, all in Belmont Addition to the City of Grand Island, Hall County, Nebraska. This Transfer -On -Death is made pursuant to Neb. Rev. Stat. §76-3401 et seq. The following warnings set forth are required pursuant to Neb. Rev. Stat. §76-3410(b)(1): 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 Transferee 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 Transferee 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. Executed on this / day of A , 2020 ENTERED AS INSTRUMENT NO