Fill and Sign the Administration of Estates and Trusts West Virginia Code Form

-1- THE ________________ _COURT OF _______________________ COUNTY, WEST VIRGINIA In Re the Estate of: ___________________ Name of the Deceased ) ) ) ) ) ) CIVIL ACTION NO. ___________________ ) ) RENUNCIATION AND DISCLAIMER OF PROPERTY I. Pursuant to the West Virginia Code, Chapter 42, Article 6, the undersigned, _______________________, chooses to exercise his/her right to disclaim a partial interest or the entire interest in the described property. II. The undersigned has an interest in the property in the above-captioned estate of _______________________ (decedent) who died on _______________________. III. The undersigned attests that the disclaimer of the property interest will be filed no later than six months after the death of the decedent. IV. Pursuant to the provisions of paragraph ______________________________ of decedent's last will and testament dated _______________________ (the "Will"), _______________________ is entitled to receive the following property: _______________________ Pursuant to applicable law of the State of West Virginia, and the Internal Revenue Code of 1986, if applicable, the undersigned hereby renounces and disclaims any interest or right to the property or asset of the deceased described in paragraph IV. -2- VI. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. VII. This renunciation and disclaimer shall for all purposes be deemed to relate back to the date of decedent's death and is an irrevocable refusal to accept that property effected hereby, and is hereby delivered to the personal representative, executor or executrix of the Estate of ____________ to be filed with the court in the above-captioned proceeding. DATED this the ______ day of ____________, 20______. _________________________(Name) -3- STATE OF WEST VIRGINIA COUNTY OF This instrument was acknowledged before me on (date) by (name or names of person or persons acknowledging). (Seal) Notary Public My commission expires: Type or Print Name I certify that on the ______ day of ____________, 20______, I delivered a true copy of the Renunciation and Disclaimer of Property by personal delivery, registered mail, and/or certified mail to ________________________________________________ (name and address), the personal representative, executor, executrix, or other fiduciary of the decedent. DATED this the ______ day of ____________, 20______. Signature of Party Printed Name Address City, State, and Zip Telephone Number -4- Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of __________________, 20______. Signature Type or Print Name Personal Representative/Executor/Executrix