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REVOCABLE TRANSFER ON DEATH DEED <br />OTICE TO OWNER: <br />ou should carefully read all information on this form. If you are married and both <br />pouses do not sign this deed, the deed may be void. <br />CJ <br />CD <br />ARNING: The property transferred remains subject to inheritance taxation in <br />ebraska to the same extent as if owned by the transferor at death. Failure to timely <br />ay inheritance taxes is subject to interest and penalties as provided by law. <br />ARNING: The designated beneficiaries are personally liable, to the extent of the <br />alue of the property transferred, to account for Medicaid reimbursement to the extent <br />ecessary to discharge any such claim remaining after application of the assets of the <br />ansferor's estate. The designated beneficiaries may also be personally liable, to the <br />xtent of the value of the property, for claims against the estate, statutory allowances to <br />e transferor's surviving spouse and children, and the expenses of administration to the <br />xtent needed to pay such amounts by the personal representative. <br />ARNING: The Department of Health and Human Services may require revocation of <br />his deed in order to qualify for Medicaid assistance. This form must be recorded before <br />our death, or it will not be effective. <br />IDENTIFYING INFORMATION <br />wner Making This Deed: <br />lice M. Herbst, single <br />103 W. Koenig Street <br />rand Island, NE 6801 <br />o� <br />ON 1N3Wf1LLSNI SY a3 <br />