Fill and Sign the Disclaimer Life Insurance Form

Prepared by U.S. Legal Forms, Inc. Copyright 2016 - U.S. Legal Forms, Inc. STATE OF MISSISSIPPI RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) Control Number – MS - 01 - 03 - 1 - NOTE ABOUT COMPLETING THE FORMS The forms in this packet contain “form fields” created using Microsoft Word. “Form fields” facilitate completion of the forms using your computer. They do not limit you ability to print the form “in blank” and complete with a typewriter or by hand. If you do not see the gray shaded form fields, go the View menu, click on Toolbars, and then select Forms. This will open the forms toolbar. Look for the button on the forms toolbar that resembles a shaded letter “a”. Click in this button and the form fields will be visible. The forms are locked which means that the content of the forms cannot be changed. You can only fill in the information in the fields. 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DISCLAIMER These materials were developed by U.S. Legal Forms, Inc. based upon statutes and forms for the State of Mississippi. All Information and Forms are subject to this Disclaimer: All forms in this package are provided without any warranty, express or implied, as to their legal effect and completeness. Please use at your own risk. If you have a serious legal problem we suggest that you consult an attorney. U.S. Legal Forms, Inc. does not provide legal advice. The products offered by U.S. Legal Forms (USLF) are not a substitute for the advice of an attorney. THESE MATERIALS ARE PROVIDED "AS IS" WITHOUT ANY EXPRESS OR IMPLIED WARRANTY OF ANY KIND INCLUDING WARRANTIES OF MERCHANTABILITY, NONINFRINGEMENT OF INTELLECTUAL PROPERTY, OR FITNESS FOR ANY PARTICULAR PURPOSE. IN NO EVENT SHALL U. S. LEGAL FORMS, INC. OR ITS AGENTS OR OFFICERS BE LIABLE FOR ANY DAMAGES WHATSOEVER (INCLUDING, WITHOUT LIMITATION DAMAGES FOR LOSS OF PROFITS, BUSINESS INTERRUPTION, LOSS OF INFORMATION) ARISING OUT OF THE USE OF OR INABILITY TO USE THE MATERIALS, EVEN IF U.S. LEGAL FORMS, INC. HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. - 2 - IN THE CHANCERY COURT OF ___________ COUNTY STATE OF MISSISSIPPI IN THE MATTER OF THE ESTATE OF ) ____________________________________ ) NO. ____________ DECEASED ) ) ) RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) I. Pursuant to the Mississippi Code, Title 89, Chapter 021, the undersigned, ______________________________ , has an interest in a life insurance policy and/or an annuity contract that he/she chooses to exercise his/her right to disclaim any interest in the policy and/or the contract. The identifying policy/contract information is as follows: ________________________________________________________________________ II. The undersigned has an interest in the property in the above-captioned policy/contract of ______________________________ (the 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. - 3 - IV. The undersigned is entitled to receive the following property: ________________________________________________________________________ V. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. VI. Pursuant to applicable law of the State of Mississippi, 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. 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. DATED this ______ day of __________________ , 20 ______ . _________________________ (Name) State of Mississippi County of __________________ - 4 - Personally appeared before me, the undersigned authority in and for said county and state, on this ______ day of __________________ , 20 ______ , within my jurisdiction, the within named ______________________________ , who acknowledged that he/she/they executed the above and foregoing instrument. Notary Public My commission expires:       Type or Print Name 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 _ ______ day of __________________ , 20 ______ .       Signature of Party       Printed Name       Address       City, State, and Zip       Telephone Number Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of __________________ , 20 ______ . Name       Type or Print Name Personal Representative/Executor/Executrix - 5 -