Fill and Sign the Disclaimer Form 497307843

( Name, Address of Party or attorney) _____________________________ _____________________________ _____________________________ State Bar No: __________________ (____) _____ - _________________ Attorney for _______ (Or "In Pro Per" or "Pro Se") ______________ COURT OF THE STATE OF KENTUCKY ___________________ JUDICIAL DISTRICT COUNTY OF ________________ IN RE: ESTATE OF ___________ ) CASE NO.: __________________ __________________________, ) DECEASED ) RENUNCIATION AND DISCLAIMER OF PROPERTY I. Pursuant to the Kentucky Statutes, Title 34, Chapter 394, the undersigned, _______________, chooses to exercise his/her right to disclaim ( ) a partial interest or ( ) the entire interest in the described property. II. The undersigned has an interest in the property in the above-captioned estate of ____________________ (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. Pursuant to the provisions of paragraph ___________ of decedent's last will and testament dated _____________________ (the "Will"), ______________ is entitled to receive the following property: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ V. Pursuant to applicable law of the State of Kentucky, 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. VI. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. 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 Estate of _____________________ to be filed with the court in the above-captioned proceeding. DATED this ____________ day of __________________, 20_______. _________________________ (Name) Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this _________ day of __________________, 20_______. _______________________________ (Name)________________ Personal Representative/Executor/Executrix State of Kentucky County of _____________________ The foregoing instrument was acknowledged before me this _________________ (date) by _____________________________________ (name of person acknowledged). ______________________________ Notary Public Title (and Rank): _______________ Print Name: ___________________ (Seal, if any) My commission expires: _____________________ I certify that on ____________ ___________, 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 _________ day of _________, 20_________. _________________________________ Signature _________________________________ Print Name _________________________________ Address _________________________________ City, State, Zip Code _________________________________ Telephone