Fill and Sign the Indiana Renunciation and Disclaimer of Property from Life Insurance or Annuity Contract Indiana Form

RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) I. Pursuant to the Indiana Code, Title 29, Chapter 2, 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 _____________________________. 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. The undersigned also delivered the disclaimer ( ) in person or ( ) by first class United States mail to the issuer of the policy or annuity not later than nine months after the death of the insured or annuitant. IV. The undersigned is entitled to receive the following property: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 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 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. 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 INDIANA COUNTY OF __________________ 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 ____________ ___________, 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