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CASH CHECK /47 J. ZZ6909Z0Z Prepared by and Return to: Jerry D. Clinch, #25651 108 2°d Street Hordville, NE 68846 INS T IO2h O S^ 2 2 TRANSFER ON DEATH DEED REFUNDS: CASH CHECK RECORDED HAL! COUNTY NE 205 St: ' Li = 3: 10 WOLD REGISTER OF DEEDS THIS TRANSFER ON DEATH DEED is made by JAMES R. SMITH ("Transferor"). Transferor hereby designates WILLIAM C. SMITH and JAMIE M. SMITH HERNANDEZ as the designated beneficiaries of the real property described below. Upon the death of Transferor, and effective only upon the death of Transferor, all of Transferor's right, title, and interest in the following described real property located in Hall County, Nebraska, shall transfer to WILLIAM C. SMITH and JAMIE M. SMITH HERNANDEZ, each as to an equal undivided one-half (1/2) interest: Lot Three (3), in Block Two (2), in Dale Roush Second Subdivision in the East Half of the Southwest Quarter (E1/2SW1/4) of Section Fourteen (14), Township Eleven (11) North, Range Ten (10), West of the 6th P.M., Hall County, Nebraska. This deed is intended to operate as a transfer on death deed under the Nebraska Uniform Real Property Transfer on Death Act. During Transferor's lifetime, this deed does not create any legal or equitable interest in favor of a designated beneficiary and does not limit Transferor's right to transfer, encumber, or otherwise deal with the property. This transfer on death deed is revocable as provided by Nebraska law. The designated beneficiaries shall take the property subject to the provisions of the Nebraska Uniform Real Property Transfer on Death Act, including the statutory survival requirements and rules governing concurrent beneficiaries. STATUTORY WARNINGS WARNING: The property transferred remains subject to inheritance taxation in Nebraska to the same extent as if owned by the transferor at death. Failure to timely pay inheritance taxes is subject to interest and penalties as provided by law. WARNING: The designated beneficiary is personally liable, to the extent of the value of the property transferred, to account for medicaid reimbursement to the extent necessary to discharge 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. /G 1