Fill and Sign the Has an Interest in Form

-1- RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) I. Pursuant to the Revised Code of Washington, Title 11, Chapter 11.86, 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. IV. The undersigned is entitled to receive the following property: -2- 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 Washington, 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 WASHINGTONCOUNTY OF On this day of , , before me personally appeared (name of person acknowledging) to me known to be the person who executed the foregoing instrument, -3- and he/she/they thereupon duly acknowledged to me that he/she/they executed the same to be his/her/their free act and deed. Notary PublicPrint 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 Print Name Address City, State, Zip Code Telephone -4- Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this day of , 20 . (Name) Personal Representative/Executor/Executrix