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202300130 We, the undersigned 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 her interest in the described real property and that she signs it willingly, and that she executes it as her free and voluntary act for the purposes 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. 4) A.11 -►rte Witness <91,&JClvIelegerlA2 Witness. STATE OF NEBRASKA. COUNTY OF HALL ) Subscribed, sworn to, and acknowledged before me by DEANNA D. JACOBSEN the transferor, and subscribed and sworn to before me by Seto -a and 143411-e— +��+-, , witnesses, this /O#±day of:14 nom11 , 2023. GENERAL NOTARY - State of Nebraska ECHO A. ALCORN My Comm. Exp. March 21, 2028 a. Notary 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. WARNING: This deed must be recorded (i) within thirty days after being executed as required in section 76-3409, (ii) before the transferor's death, and (iii) in the public records in the office of the register of deeds of the county where the property is located. Page 2 of 2