Fill and Sign the Disclaimer Property Interest Form

RENUNCIATION AND DISCLAIMER OF PROPERTY (Real Property Interest) I. Pursuant to the Mississippi Code, Title 89, Chapter 021, 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 Mississippi and the Internal Revenue Code of 1986, if applicable, the undersigned hereby renounces and disclaims any interest or right to the real 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. 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) Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this _________ day of __________________, 20_______. _______________________________ (Name)________________ Personal Representative/Executor/Executrix STATE OF MISSISSIPPI COUNTY OF _________________ Personally appeared before me, the undersigned authority in and for said county and state, on this __________ day of ___________________________, _________, within my jurisdiction, the within named ______________________________, who acknowledged that (he/she/they) executed the above and foregoing instrument. ______________________________ Notary Public Printed Name: _________________ 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, return receipt requested, 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