______________________________________________________________________________

TRANSFER ON DEATH DEED

NOTICE TO OWNER

You should carefully read all information on this form. You may want to consult a lawyer before using this form.

This form must be recorded before your death or it will not be effective.

TAX STATEMENT

Until a change is requested, the county clerk shall send tax statements to the following address: _______________

IDENTIFYING INFORMATION

Owner or Owners Making This Deed:

Printed name: _________

Mailing address: _________

Printed name: _________

Mailing address: _________

Legal description of the property:

PRIMARY BENEFICIARY

I designate the following beneficiary if the beneficiary survives me:

Printed name: _________

Mailing address, if available:

ALTERNATE BENEFICIARY

If my primary beneficiary does not survive me, I designate the following alternate beneficiary if that beneficiary survives me:

Printed name: _________

Mailing address, if available:

TRANSFER ON DEATH

At my death, I transfer my interest in the described property to the beneficiaries as designated above.

Before my death, I have the right to revoke this deed.

SPECIAL TERMS

RETURN OF DEED

After recording, the county clerk shall return the deed to: _______________

SIGNATURE OF OWNER OR OWNERS

MAKING THIS DEED

Signature: _________

Date: _________

Signature: _________

Date: _________

State of _________

County of _________

This instrument was acknowledged before me on ___ (date) by _________. (name(s) of person(s))

Title (and Rank)

My commission expires: _________

______________________________________________________________________________ [2011 c.212 §16]

Note: See note under 93.948.