Fill and Sign the Indiana Property 497306821 Form

State of Indiana County of ________       __________ - _________ In The _____________________________________________________ Court In Re the Estate of: Name of the Deceased ) ) ) ) ) ) NO. _______________________ ) RENUNCIATION AND DISCLAIMER ) OF PROPERTY (Intestate Succession) ) ) ) I. Pursuant to the Indiana Code, Title 29, 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 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. - 1 - IV. 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 Indiana, 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 INDIANA COUNTY OF       - 2 - Before me, the undersigned, a Notary Public, in and for said County and State, this       day of       ,       , personally appeared       , said person being over the age of 18 years, and acknowledged the execution of the foregoing instrument.       Notary Public Print 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 - 3 - Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this       day of       , 20       .       (Name)       Personal Representative/Executor/Executrix - 4 -