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202605514 <br />SPACE ABOVE THIS LINE FOR RECORDER'S USE <br />REVOCABLE TRANSFER ON DEATH DEED <br />YOU SHOULD CAREFULLY READ ALL INFORMATION ON THIS FORM. YOU <br />MAY WANT TO CONSULT A LAWYER BEFORE USING THIS FORM. IF YOU <br />ARE MARRIED AND BOTH SPOUSES DO NOT SIGN THIS DEED, THE DEED <br />MAY BE VOID. <br />WARNING: The property transferred remains subject to inheritance taxation in Nebraska to the <br />same extent as if owned by the transferor at death. <br />WARNING: The designated beneficiary is personally liable to account for Medicaid <br />reimbursement to the extent necessary to discharge any such claim remaining after application of <br />the assets of the transferor's estate. The designated beneficiary may also be personally liable for <br />claims against the estate, statutory allowances to the transferor's surviving spouse and children, and <br />the expenses of administration to the extent needed to pay such amounts by the personal <br />representative. <br />WARNING: The Department of Health and Human Services may require revocation of this deed <br />in order to qualify for Medicaid assistance. <br />This form must be recorded before your death, or it will not be effective. <br />Page 3 of 7 <br />