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LZ660EZOZ <br />MST 2223 0 t a 2 <br />CASH 9° <br />CHECK <br />REFUNDS: <br />CASH <br />CHECK <br />w.� <br />.R GISTER OF <br />5b <br />Return to: Duane A. Burns, 308 N. Locust Street, Grand Island, NE 68801 <br />REVOCABLE TRANSFER ON DEATH DEED <br />NOTICE TO OWNER: <br />You should carefully read all information on this form. If you are married and both <br />spouses do not sign this deed, the deed may be void. <br />WARNING: The property transferred remains subject to inheritance taxation in <br />Nebraska to the same extent as if owned by the transferor at death. Failure to timely <br />pay inheritance taxes is subject to interest and penalties as provided by law. <br />WARNING: The designated beneficiary is personally liable, to the extent of the value of <br />the property transferred, to account for Medicaid reimbursement to the extent necessary <br />to discharge any such claim remaining after application of the assets of the transferor's <br />estate. The designated beneficiary may also be personally liable, to the extent of the <br />value of the property, for claims against the estate, statutory allowances to the <br />transferor's surviving spouse and children, and the expenses of administration to the <br />extent needed to pay such amounts by the personal representative. <br />WARNING: The Department of Health and Human Services may require revocation of <br />this deed in order to qualify for Medicaid assistance. This form must be recorded before <br />your death, or it will not be effective. <br />IDENTIFYING INFORMATION <br />OWNER Making This Deed: <br />Jerry D. Case <br />2316 W. 11th Street <br />Grand Island, NE 68803 <br />LEGAL DESCRIPTION OF THE PROPERTY <br />Lot Twelve (12), in Block Three (3), Dill & Huston's Addition to the City of <br />Grand Island, Hall County, Nebraska. <br />I designate the following beneficiary: <br />Julie Klein <br />16444 S. 73rd <br />Roca, NE 68430 <br />BENEFICIARY <br />1 <br />00 <br />