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202205529 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. B. The designated beneficiary 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 designated beneficiary 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. C. 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 Owner Making This Transfer on Death Deed I, Ann R. Chambers, the transferor, sign my name to this instrument on July to S , 2022, and being first duly sworn, do hereby declare to the undersigned authority that I sign and execute this transfer on death deed to transfer my interest in the described real property and that I sign it willingly, that I execute it as my free and voluntary act for the purposes therein expressed, that I am eighteen years of age or older or am not at this time a minor, and that I am of sound mind and under no constraint or undue influence. t R. C _ambers, Transferor 11(LA-- We, Mary Hollowell and Peachis Amadou, the witnesses, sign our names to this instrument, being first duly sworn, and do hereby declare to the undersigned authority that the transferor signs and executes this transfer on death deed to transfer his or her interest in the described real property and that he or she signs it willingly or willingly, and that he or she executes it as his or her free and voluntary act for the purpose therein expressed, and that each of us, in the presence and hearing of the transferor, hereby signs this deed as witness to the transferor's signing, and that to the best of his or her knowledge the transferor is eighteen years of age or older or is not at this time a minor and the transferor is of sound mind and under no constraint or undue influence. fitness' Name STATE OF NEBRASKA ) ) SS. COUNTY OF HALL ) Grand Island, NE Witness' Address Grand Island, NE Witness' Address ACKNOWLEDGMENT Subscribed, sworn to, and acknowledge before me by Ann R. Chambers, the transferor, and subscribed and sworn to before me by Mary Hollowell and Peachis Amadou, witnesses, this 05 day of July, 2022. GENERAL NOTARY - State of Nebraska u� STACIE A. GODING [Seal] �1� pry Comm. Exp. October 18, 2025 N • t. Public 2