Fill and Sign the In County Oregon Circuit Court Form

1 2 345 6 789 101112131415161718192021 22 232425 26 2728 IN __________________ COUNTY, OREGON, CIRCUIT COURT PROBATE DEPARTMENT In the Matter of: ) ) ____________________________________ )Case No. __________________Decedent. ) RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) ____________________________________________________________________________ I. Pursuant to the Oregon “Uniform Disclaimer of Property Interests Act”, Oregon Revised Statutes, Chapter 245, 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 __________________, 20______. III. The undersigned is entitled to receive the following property:________________________________________________________________________ 1 2 345 6 789 101112131415161718192021 22 232425 26 2728 IV. VI. Pursuant to applicable law of the State of Oregon, 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 III. 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 ______________________________, of ________________________, the company or organization obligated to make the distribution.DATED this ____________ day of __________________, 20_______. _________________________ (Name) STATE OF OREGONCOUNTY OF __________________ This instrument was acknowledged before me on __________________ (date) by ______________________________. (name(s) of person(s)) Notary PublicMy commission expires: Type or Print Name 1 2 345 6 789 101112131415161718192021 22 232425 26 2728 Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this _________ day of __________________, 20_______. Company or OrganizationSignature Type or Print NameSTATE OF OREGONCOUNTY OF __________________ This instrument was acknowledged before me on __________________ (date) by ______________________________ (name(s) of person(s)) as ________________________ (type of authority, e.g., officer, trustee, etc.) of ______________________________. (name of party on behalf of whom instrument was executed) Notary PublicMy commission expires: Type or Print NameI 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 ______________________________ of ________________________. DATED this _________ day of _________, 20_________. Signature of Party Printed Name Address City, State, and Zip Telephone Number