Fill and Sign the Disclaimer Form 481370409

IN THE _______________________ (Name of Court) COURT OF ______________________ (Name of County), ___________________________ (Name of State) In the Matter of the Estate Of ___________________________ (Name of Decedent),Deceased Cause No. ______________ Renunciation and Disclaimer of Life Insurance 1. Pursuant to the ______________________ (Name of State)’s Uniform Disclaimer of Property Interests Act, _____________________ (Name of State) Statutes, Chapter _______ (number), the undersigned, _________________ , has an interest in a life insurance policy and he/she chooses to exercise his/her right to disclaim any interest in the said policy. The identifying policy information is as follows: (For example: Policy Number 123456 with Nobody Life Insurance Company, the death proceeds of which is $_______________) ______________________________________________________________________ ______________________________________________________________________ 2. The undersigned has an interest in the death proceeds of the above described policy of the Decedent who died on ________________________ (date) in that the undersigned is the Primary Beneficiary. 3. The undersigned is therefore entitled to receive the death proceeds of said policy which amounts to $_______________. 4. Pursuant to applicable law of the State of _______________________ (Name of State), 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 3. 5. 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 ______________________________________ (Name of Insurance Company) , the company or organization obligated to make the distribution. Respectfully submitted: ________________________________________________ Printed Name and Signature of Primary Beneficiary STATE OF __________________ (Form of Oath/Acknowledgement may vary by state) COUNTY OF ____________________ Personally appeared before me, the undersigned authority at law in and for the aforesaid jurisdiction, the within-named __________________________ (Name of Primary Beneficiary), who, after having been first duly sworn, stated on oath that the matters and facts set forth in the above and foregoing Petition are true and correct as therein stated. _______________________________________________ Printed Name and Signature of Primary Beneficiary SWORN to and subscribed before me, this the _____ day of _____________________, 20______. __________________________ NOTARY PUBLIC My Commission Expires: ____________________