Fill and Sign the Disclaimer Property Interest Form

RENUNCIATION AND DISCLAIMER OF PROPERTY (Real Property Interest) I. Pursuant to the West Virginia Code, Chapter 42, Article 6, 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 six months after the death of the decedent. V. Pursuant to applicable law of the State of West Virginia 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. - 1 - 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 ______ . Signature       Type or Print Name - 2 - STATE OF WEST VIRGINIA COUNTY OF ________________________ This instrument was acknowledged before me on ______ (date) by __________________ (name or names of person or persons acknowledging). ______________________________ Notary Public Printed 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 of Party       Printed Name       Address       City, State, and Zip - 3 -       Telephone Number - 4 - 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 - 5 -