Fill and Sign the Hawaii Renunciation Form

RENUNCIATION AND DISCLAIMER OF PROPERTY (Individual Retirement Account, Annuity, or Bond) I. Pursuant to the Hawaii Revised Statutes, Chap. 526, the undersigned, _______________ , has an interest in ( ) an Individual Retirement Account, and/or ( ) an Annuity, and/ or ( ) a Bond. The identifying account and/or bond information is as follows: ______________________________________________________________________________ ______________________________________________________________________________ II. The undersigned has an interest in the property in the above-captioned proceeds 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 proceeds: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 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 Hawaii, 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) Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this _________ day of __________________, 20_______. _______________________________ (Name)________________ Personal Representative/Executor/Executrix STATE OF HAWAII COUNTY OF ____________________ On this ___________ day of _______________________, 20 _____________, before me personally appeared _____________________________________________, to me known to be the person (or persons) described in and who executed the foregoing instrument, and acknowledged that he/she/they executed the same as his/her/their free act and deed. ______________________________ Notary Public Print 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 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