Fill and Sign the In the Judicial District Court County State of Utah Form

-1- Petitioner’s Name Address (may be omitted for privacy) City, State, ZIP Telephone (may be omitted) IN THE JUDICIAL DISTRICT COURT ___________________ COUNTY, STATE OF UTAH In Re the Marriage of: Name of the Deceased)))))Civil No. _____________________)Judge ________________________))))) RENUNCIATION AND DISCLAIMER OF PROPERTY (Intestate Succession) I. Pursuant to the Utah Uniform Probate Code, Title 75, Chapter 2, the undersigned, , chooses to exercise his/her right to disclaim a partial interest or the entire interest in the described property. II. The decedent died intestate on , 20 and the undersigned has an interest in the described property. III. Pursuant to intestate succession, the undersigned has an interest in the following property: -2- IV. The undersigned attests that the disclaimer of the property interest will be filed no later than nine months after the death of the decedent. V. Pursuant to applicable law of the State of Utah, 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. 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 decedent.DATED this day of , 20 . (Name) -3- STATE OF UTAHCOUNTY OF The foregoing instrument was acknowledged before me this (date) by (person acknowledging, title or representative capacity, if any).(Seal) Notary PublicPrinted 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