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202505212 any such claim remaining after application of the assets of the transferor's estate. The designated beneficiary may also be personally liable, to the extent of the value of the property transferred, 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 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. IN WITNESS WHEREOF, Owner (Transferor) duly executed this instrument on the 11 day of September 2025. Signature: v Print Name: Ji O' livain Y We, the undersigned witnesses, sign our names to this instrument, being first duly sworn, and do hereby declare to the undersigned authority that the Owner (Transferor) signs and executes this transfer on death deed to transfer interest in the described real property and that Owner (Transferor) signs it willingly or willingly directs another to sign on their behalf, and that Owner (Transferor) executes it as their free and voluntary act for the purposes therein expressed, and that each of us, in the presence and hearing of Owner (Transferor), hereby signs this deed as witness to the signing of Owner (Transferor), and that to the best of their knowledge Owner (Transferor) is eighteen years of age or older or is not at this time a minor and the Owner (Transferor) is of s • d mind and under no constraint or undue influence. i Signa 6/Ce 7>nkJfe Q/1 Name Witness 1 0M/ Jarc 1D q C cc Le Street Address rtIti N Lo W0 I City, State, Zip Code of Witness 1 Signature of Witness 2 C}M t3 CbRm Name of Witness 2 ?LcSLitcpICJ S - e S� Street Address C998b City, State, Zip Code Page 3