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202404021 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 I, Ouphayvanh Boutmahavong, a single person, the transferor, sign my names to this instrument on • , 2024, and being first duly sworn, do hereby declare to the undersigned authority that I sign and execute this transfer on death deed to transfer my interest in the described real property and that I sign it willingly or willingly direct another to sign for me, that I execute it as my free and voluntary act for the purposes therein expressed, that I am eighteen years of age or older or am not at this time a minor, and that I am of sound mind and under no constraint or undue influence. Warning: The two witnesses must be disinterested for this Deed to be valid. An interested witness means any individual who on the date that this deed is or would be entitled to receive any interest in the land under this transfer on death deed if the transferor died under the circumstances existing at the date of the signing of this deed or any child, spouse or heir of that person. We, iesse l`Ic, Caccia - MbtdQ . and 4,) , the witnesses, sign our names to this instrument, being first duly sworn, and do hereeclare 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 directs another to sign for him or her, and that he or she execute it as his or her free and voluntary act for the purposes 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. 308 N. Locust, Ste. 501, Grand Island, NE 68801 Witness' Address 308 N. Locust, Ste. 501, Grand Island, NE 68801 Witness' Name Witness' Address Acknowledgement STATE OF NEBRASKA, COUNTY OF HALL, SS: Subscribed, sworn to, and acknowledged before me by Ouphayvanh Boutmahhj�vong,the transferor, and subscribed and sworn to before me by icy' - U�i�:rr.nd CSL%/ witnesses, this I day of , 2024. [Seal] Nota My Coi mission GENERAL NOTARY - State of Nebraska ZACHARY BUTZ My Comm. Exp. May 16, 2025 Transfer on Death Deed - Page No. 3