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202300418 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 We, Lyndall R. Hulit and Mary K. Hulit, the transferors, sign our names to this instrument on January 26, 2023, and being first duly sworn, do hereby declare to the undersigned authority that we sign and execute this transfer on death deed to transfer our interest in the described real property and that we sign it willingly, that we execute it as my free and voluntary act for the purposes therein expressed, that we are eighteen years of age or older or are not at this time minors, and that we are of sound mind and under no constraint or undue influence. leca7e).1:4c-a2 Lynd 11R. Hulit, Transferor MH lit, , Transferor We, l'dANvalatF n and 3e -F-4 Ey r1e-iu•� , 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. Witness' Narre STATE OF NEBRASKA ) ) SS. COUNTY OF HALL ) 6-vid /faiid7 Ai& Witness' Address C-o-.rNA. -ntatoci oJ� Witness' Address ACKNOWLEDGMENT Subscribed, sworn to, and acknowledge before me by Lyndall R. Hulit and Mary K. Hulit, the transferors, and subscribed and sworn to before me by lGzl.1 knd.o.vsur\ 4z -v\01 7e -re Ctfne ts. , witnesses, this 26th day of January, 2023. [Seal] GENERAL NOTARY - State of Nebraska STACIE A. GODING My Comm. Exp. October 18, 2025 2