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_eturn to: <br />Notice to Owner: <br />CASH <br />CHECK [ (p o° <br />REFUNDS: <br />CASH <br />CHECK <br />111 T <br />iV <br />Denise Myers;Attorney <br />P.O. Box 505 <br />Cairo, NE 68824 <br />REVOCABLE TRANSFER ON DEATH DEED <br />OLD <br />11 <br />You should carefully read all information on this form. You may want to consult a Lawyer before using this Form. If <br />you are married and both spouses do not sign this deed, the deed may be void. <br />This form must be recorded with the Register of Deeds of the County in which the property is located before your death <br />and it also must be recorded with the Register of Deeds of the County in which the property is located within 30 days <br />after it was signed. If either of these requirements is not met, this form will not be effective. <br />Identifying Information about Owner: <br />Names of Owner: Mailing Address of Owner: <br />Barbara M. Wieczorek 3936 W Capital Avenue <br />(a single person) Grand Island, NE 68803 <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 Death deed under Neb. <br />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 the Primary Beneficiary <br />or to the appropriate Alternate Beneficiary as provided below. <br />Lot Seven (7), in the Northwest Subdivision, compromising a part of the Northwest Quarter of the <br />Northwest Quarter (NW1/4NW1/4) of Section Twelve (12), Township Eleven (11) North, Range Ten <br />(10), West of the 6th P.M., Hall County, Nebraska <br />Primary Beneficiary: <br />I designate the following beneficiaries of this revocable transfer on death deed (as tenants in common) if the <br />beneficiaries survive me: <br />Name of Primary Beneficiaries: Mailing Address of Primary Beneficiaries: <br />Sharon McCoy 20605 U Court #6208, Elkhorn, NE 68022 <br />Linda Elley 1402 Larkspur Drive, Scottsbluff, NE 69361 <br />Paul Wieczorek 6130 First Street, Superior Township, MI 48198 <br />Sandy Wieczorek 9754 Spring Ridge Circle, Estero, FL 33928 <br />Dave Wieczorek 924 East Capital, Grand Island, NE 68801 <br />Joan Ruskamp 1747 Road W, Dodge, NE 68633 <br />Transfer on Death: <br />At my death I transfer my interest in the described property to the beneficiaries as designated above. The transfer <br />occurs at my death. <br />Survivorship Required: <br />Under Nebraska Law, the interest of a designated beneficiary is contingent on the designated beneficiary surviving the <br />transferor by one hundred twenty (120) hours. <br />This TOD Deed is Revocable: <br />Before my death, I have the right to revoke this deed. <br />