Fill and Sign the Disclaimer Property Statement Form

-1- IN THE IOWA DISTRICT COURT FOR ____________________ COUNTY In Re the Estate of: Name of the Deceased ) ) ) ) ) ) NO. _______________________ ) RENUNCIATION AND DISCLAIMER ) OF PROPERTY ) ) ) I. Pursuant to the Iowa Code Chapter 633 E and Section 2518 of the Internal Revenue Code of 1986, as amended, 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 -capt ioned estate of ____________________ (decedent) who died on ____________________ . III. 1 . I irrevocably and without qualification renounce, release, decline, disclaim and refuse to accept any and all rights or interest in and to the following specifically described property or property ri ghts (the "disclaimed property"): ____________________ -2- 2. The disclaimed prope rty was to pass to the Disclaimant pursuant to Article ____________________ of the ___ _________________ (name of decedent) Last Will and Testament which h as been admitted to probate as above set forth. 3. This Disclaimer is irrevocable and I waive and renounce any right to amend or revoke this Disclaimer in any manner. 4. I have not accepted the disclaimed property or any interest in or benefits from the disclaimed property. 5. I have not accepted or agreed or contracted to receive or accept any consideration in return for this Disclaimer. 6. I was not insolvent as of the date of execution of this Disclaimer and have not been insolvent at any point in ti me since my rights in the disclaimed property were finally ascertained and indefeasibly forfeited. 7. I have not voluntarily assigned or transferred or contracted to assign or transfer any interest in the disclaimed property or waived the right to disclai m such property. 8. I have not sold or otherwise disposed of any interest in the disclaimed property or the disclaimed property has not been sold or otherwise disposed. 9. I intend this Disclaimer to be a "Qualified Disclaimer" under the Internal Revenue Code Section 2518 and it shall be construed accordingly. -3- IV. Pursuant to applicable law of the State of Iowa and the Internal Revenue Code, if applicable, the undersig ned hereby renounces and disclaims any interest or right to the property or asset of the deceased described in paragraph s III . If as a result of a disclaimer or transfer the disclaimed or transferred interest is treated pursuant to the provisions of Title 26 of the United States Code, as now or hereafter amended, or any successor statute thereto, and the regulations promulgated thereunder, as never having been transferred to the disclaimant, then the disclaimer or transfer is effective as a disclaimer . V. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. VI. 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 exec utrix of the Estate of ____________________ to be filed with the court in the above -captioned proceeding. DATED this ______ day of _____________ , 20 ______ . _______________________________________ Signature _____________ (Name) -4- STATE OF IOWA COUNTY _____________ On this ______ day of _____________ , ______ , before me, a Notary Public, personally appeared _____________ , to me known to be the person named in and who executed the foregoing instrument, and acknowledged that he/she/they executed the same as his/her/th eir voluntary act and deed. ______________________________ Notary Public Print Name: _____________ -5- 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 _____________ Print Name _____________ Address _____________ City, State, Zip Code _____________ Telephone -6- Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of _____________________ , 20 ______ . _____________________________________ _____________________ (Name) Personal Representative/Executor/Executrix