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HIST 1113 0 0 S 1 it <br />CHECK a797.GO <br />REFUNDS: <br />CASH <br />CHECK <br />RCC <br />HALL C,-;7) <br />1013 FE ,.. <br />i`p4_GV: i E. f, <br />': 43 <br />Return to: Jeanette P. Moe <br />v/ 705 Dean Street <br />Grand Island, NE 68801 <br />REVOCABLE TRANSFER ON DEATH DEED <br />(single owner) <br />Notice to Owners <br />You should carefully read all information on this form. <br />This transfer on death deed must be recorded with the Register of Deeds of the County in which <br />the property is located, before your death and within 30 days after being signed. If either of these <br />requirements is not met, this transfer on death deed will not be effective. <br />Identifying Information about Owners <br />Name of Owners Mailing Address of Owners <br />Jeanette P. Moe <br />705 Dean Street <br />Grand Island, NE 68801 <br />Notice to Register of Deeds <br />This is a transfer on death deed, and Form 521 is not required with the filing of this transfer on <br />death deed under Neb. Rev. Stat. §76-214(2)(b). <br />Legal Description <br />The following real estate is transferred by this document, effective at the death of the Owner, to <br />the Beneficiaries as provided below. <br />The West 54.37 feet of Lot Nine (9) and the East 54.76 Feet of Lot Ten (10) in Dean <br />Subdivision Hall County, Nebraska. <br />Primary Beneficiaries <br />I designate the following beneficiaries of this revocable transfer on death deed if the <br />beneficiaries survive me. <br />Names of Primary Beneficiaries Mailing Address of Primary Beneficiary <br />Shawn R. Flebbe <br />2508 Cottonwood Road <br />Grand Island, NE 68801 <br />Brian M. Flebbe 806 W. 13 Street <br />Grand Island, NE 68801 <br />Transfer on Death <br />At my death, I transfer my interest in the described property to the beneficiaries as designed above <br />who may then survive me. The Transfer occurs at the death of the Transfer. <br />Survivorship Required <br />Under Nebraska law, the interest of a designated beneficiaries is contingent on the designated <br />beneficiaries surviving the Transferor by one hundred twenty hours. <br />Page 1 of 3 <br />