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202107018 <br />This TOD Deed is Revocable: <br />Before my death, I have the right to revoke this Deed. <br />Warning: <br />The property transferred remains subject to inheritance taxation in Nebraska to the <br />same extent as if owned by the transferor at death. Failure to timely pay inheritance <br />taxes is subject to interest and penalties as provided by law. <br />Warning: <br />The designated beneficiary is personally liable, to the extent of the value of the <br />property transferred, to account for Medicaid reimbursement to the extent necessary <br />to discharge any such claim remaining after application of the assets of the <br />transferor's estate. The designated beneficiary may also be personally liable, to the <br />extent of the value of the property transferred, for claims against the estate, statutory <br />allowances to the transferor's surviving spouse and children, and the expenses of <br />administration to the extent needed to pay such amounts by the personal <br />representative. <br />Warning: <br />The Department of Health and Human Services may require revocation of this Deed by <br />a transferor, a transferor's spouse, or both a transferor and the transferor's spouse in <br />order to qualify or remain qualified for Medicaid assistance. <br />Signature of Owner Making This Transfer on Death Deed: <br />/ T1 <br />I, David L. Larson, the transferor, sign my name to this instrument on August i/ <br />2021, and being first duly sworn, do hereby declare to the undersigned authority that <br />I sign and execute this Transfer on Death Deed to transfer my interest in the described <br />real property and that I sign it willingly; that I execute it as my free and voluntary act <br />for the purposes therein expressed; that I am eighteen years of age or older and that I <br />am of sound mind and under no constraint or undue influence. <br />VID L. LA SON, Transferor <br />2 <br />