Fill and Sign the In Re Estate of Chambersnebraska Judicial Branch Form

-1- JUDICIAL BRANCH – _ DIVISION In Re the Estate of: CountyName of the Deceased Haverhill Littleton Derry Lebanon Brentwood Plymouth Portsmouth SalemRENUNCIATION AND DISCLAIMER OF PROPERTY I.Pursuant to the Revised Statutes of New Hampshire Title 56, Chapter 563-B, 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-captioned estate of (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. -2- Pursuant to the provisions of paragraph of decedent's last will and testament dated (the "Will"), is entitled to receive the following property: V. Pursuant to applicable law of the State of New Hampshire 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. VI. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. 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 Estate of to be filed with the court in the above-captioned proceeding.DATED this day of , 20 . (Name) STATE OF NEW HAMPSHIRECOUNTY OF The foregoing instrument was acknowledged before me this (date) by (name of person acknowledged). -3- Notary PublicPrint Name: My commission expires: _________________________________ Signature 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