Fill and Sign the Chapter 83 Uniform Disclaimer of Property

-1- RENUNCIATION AND DISCLAIMER OF PROPERTY (Real Property Interest) I. Pursuant to the Vermont Statutes, Title 14, Chapter 83, the undersigned, chooses to exercise his/her right to disclaim an interest in the real property which has devolved to him/her because of the death of the decedent. II. The decedent died on , 20 and the undersigned has an interest in the described real property. III. A description of the real property is as follows: IV. The undersigned attests that the disclaimer of the real property interest will be filed no later than nine months after the death of the decedent. V. Pursuant to applicable law of the State of Vermont and the Internal Revenue Code of 1986, if applicable, the undersigned hereby renounces and disclaims any interest or right to the real property of the deceased described in paragraph III. VI. The real property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. -2- 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. A copy of the disclaimer shall be recorded in the office of the county clerk and recorder of the county in which the property or interest disclaimed is located. DATED this day of , 20 . (Name) -3- STATE OF VERMONTCOUNTY OF On this day of , , before me personally appeared (name of person acknowledging) to me known to be the person who executed the foregoing instrument, and he/she/they thereupon duly acknowledged to me that he/she/they executed the same to be his/her/their free act and deed. Notary PublicPrint Name: My commission expires: 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 Print Name Address City, State, Zip Code -4- Telephone -5- Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this day of , 20 . (Name) Personal Representative/Executor/Executrix