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202207560 Name of Primary Beneficiary Mailing Address of Primary Beneficiary COLLEEN K. DELEON 912 W. 15TH STREET GRAND ISLAND, NE 68801 Alternate Beneficiary If my primary beneficiary does not survive me, I designate the following alternate beneficiary if that alternate beneficiary survives me. Name of Alternate Beneficiary Mailing Address of Alternate Beneficiary GAYLEEN K. KAMPER 2146 WEDGEWOOD DR. GREELEY, CO 80631 Transfer on Death At my death, I transfer my interest in the described property to the beneficiaries as designated above. The transfer occurs at the death of the Transferor. Survivorship Required Under Nebraska law, the interest of a designated beneficiary is contingent on the designated beneficiary surviving the transferor by one hundred twenty hours. This TOD Deed is Revocable Before my death, I have the right to revoke this deed. Required Warnings in the TOD Deed: Please pay close attention to the following warnings. 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 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. 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. Transfer on Death Deed - Page No. 2