California Renunciation and Disclaimer of Joint Tenant

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SUPERIOR COURT OF CALIFORNIA

COUNTY OF

In Re the Estate of:

Decedent.

NO.

RENUNCIATION AND DISCLAIMER OF PROPERTY
(Life Insurance or Annuity Contract)

I.

Pursuant to the California Probate Code Div. 2, Part 8, Chap. 2, the undersigned,

, has an interest in a life insurance policy and/or an annuity contract that he/she chooses to exercise his/her right to disclaim any interest in the policy and/or the contract. The identifying policy/contract information is as follows:

II.

The undersigned has an interest in the property in the above-captioned policy/contract of

(the decedent) who died on

III.

The undersigned attests that the disclaimer of the property interest will be filed no later than nine months after the death of the decedent.

IV.

The undersigned is entitled to receive the following property:

V.

The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. As a result of this renunciation and disclaimer the following individual(s) will take the interest or right to inherit the property or asset of the deceased as described in paragraph IV:

Name:

Address:

VI.

Pursuant to applicable law of the State of California, 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.

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 decedent.

DATED this day of , 20

State of California

County of

On before me, (here insert name and title of the officer), personally appeared

, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

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

Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this day of , 20