Fill and Sign the Colorado Disclaimer Form

________________ COURT, ____________________ COUNTY , COLORADO RENUNCIATION AND DISCLAIMER OF PROPERTY In Re the Estate of: ____________________ Name of the Deceased ___________________ NOTICE: THIS IS AN IMPORTANT LEGAL AGREEMENT AND HAS SUBSTANTIAL LEGAL CONSEQUENCES ON YOU, YOUR RIGHTS AND OBLIGATIONS. YOU ARE ADVISED TO CONSULT AN ATTORNEY FOR INDEPENDENT LEGAL ADVICE PRIOR TO EXECUTION OF THIS AGREEMENT. I. Pursuant to the Colorado Revised Statutes, Title 15, Art. 11, Part 12, the undersigned, _________________________ , chooses to exercise his/her right to disclaim a partial interest or the entire interest in the described property.: II. Pursuant to the provisions of paragraph ___________ of decedent's last will and testament dated _________________ (the "Will"), _______________________ is entitled to inherit ________________________________________________________________ . III. Pursuant to applicable law of the State of Colorado, and the Internal Revenue Code of 1986, if applicable, the undersigned hereby renounces and disclaims any interest or right to inherit the property or asset of the deceased described in paragraph II. - 1 - IV. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. V. 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 _______ day of ________________ , 20 ______ . ____________________________ Signature ________________________ Type or Print Name - 2 - State of Colorado County of ____________________ The foregoing instrument was acknowledged before me this Date___________ by ______________________________ (name of person acknowledged). _________________________________ Notary Public Print 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 ______________________ Telephone - 3 - 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 - 4 -