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202301374 Prepared By: James H Truell 308 N. Locust St., Ste. #306 Grand Island, NE 68801 After Recording Return To: James H Truell 308 N. Locust St., Ste. #306 Grand Island, NE 68801 SPACE ABOVE THIS LINE FOR RECORDER'S USE REVOCABLE TRANSFER ON DEATH DEED YOU SHOULD CAREFULLY READ ALL INFORMATION ON THIS FORM. YOU MAY WANT TO CONSULT A LAWYER BEFORE USING THIS FORM. IF YOU ARE MARRIED AND BOTH SPOUSES DO NOT SIGN THIS DEED, THE DEED MAY BE VOID. WARNING: The property transferred remains subject to inheritance taxation in Nebraska to the same extent as if owned by the transferor at death. WARNING: The designated beneficiary is personally liable 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 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 in order to qualify for Medicaid assistance. This form must be recorded before your death, or it will not be effective. KNOW ALL PERSONS BY THESE PRESENTS THAT: I, Lenetta J Haines, a single person, (herein referred to as "Grantor"), does hereby convey unto David P Haines, (herein referred to as "Grantee"), effective upon my death, the following described real property located in Grand Island, in the County of Hall, State of Nebraska: Page 1 of 4