Chapter 1186 RCW Disclaimer of Interests

RENUNCIATION AND DISCLAIMER OF JOINT TENANT INTEREST
(Entire Interest of Joint Tenant)

I.

Pursuant to Chapter 633E of the Code of Iowa, the undersigned, , the
surviving joint tenant with right of survivorship, chooses to exercise his/her right to disclaim any
and all interests he/ she may have in any property or interest that is the subject of a joint tenancy
devolving to him/her because of the death of the decedent.

II.

The undersigned, as the surviving joint tenant, has an interest in the property of

(the decedent) who died on

III.

As a joint tenant with right of survivorship, the undersigned has an interest in the following
property:

IV.

Pursuant to applicable law of the State of Iowa, and the Internal Revenue Code, as now or
hereafter amended, or any successor statute thereto, and the regulations promulgated thereunder
if applicable, the undersigned hereby renounces and disclaims any interest or right to the
property or asset of the deceased described in paragraph III.

V.

The property devolves to others pursuant to the provisions of applicable State law as though the
undersigned had predeceased the decedent.

VI.

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.

VII.

1. I irrevocably and without qualification renounce, release, decline, disclaim and refuse to
accept any and all rights or interest in and to the following specifically described property or
property rights (the "disclaimed property"):

2. The disclaimed property was to pass to the Disclaimant pursuant to Article
of the Last Will and Testament
which has been admitted to probate as above set forth.

3. This Disclaimer is irrevocable and I waive and renounce any right to amend or revoke this
Disclaimer in any manner.

4. I have not accepted the disclaimed property or any interest in or benefits from the disclaimed
property.

5. I have not accepted or agreed or contracted to receive or accept any consideration in return
for this Disclaimer.

6. I was not insolvent as of the date of execution of this Disclaimer and have not been insolvent
at any point in time since my rights in the disclaimed property were finally ascertained and
indefeasibly forfeited.

7. I have not voluntarily assigned or transferred or contracted to assign or transfer any interest in
the disclaimed property or waived the right to disclaim such property.

8. I have not sold or otherwise disposed of any interest in the disclaimed property or the
disclaimed property has not been sold or otherwise disposed.

9. I intend this Disclaimer to be a "Qualified Disclaimer" under the Internal Revenue Code
Section 2518 and it shall be construed accordingly.

DATED this day of , 20

STATE OF IOWA

COUNTY

On this day of , before me, a Notary Public, personally
appeared , to me known to be the person named in and who executed the
foregoing instrument, and acknowledged that he/she/they executed the same as his/her/their
voluntary act and deed.

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 , 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