Fill and Sign the Ks Property Form

RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) I. Pursuant to the Kansas Statutes, Chapter 59, Art. 22, the undersigned, _______________ , has an interest in ( ) a life insurance policy and/or ( ) an annuity contract th at 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. IV. The undersigned is entitled to receive the following property: _____________________________ _________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ V. The property devolves t o 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 Kansas, and the Internal Revenue Code of 1986, if applicable, the undersigne d 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 irr evocable 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) Re ceipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this _________ day of __________________, 20_______. _______________________________ (Name)________________ Personal Representative/Executor/Executrix STATE OF KANSAS COUNTY OF ___________________ This instrument was acknowledged to me on _______________________________ (date) by ________________________________ [name(s) of person(s)]. ______________________________ 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 mai l to the personal representative/executor/executrix or other fiduciary of the decedent. DATED this _________ day of _________, 20_________. _________________________________ Signature _________________________________ Print Nam e _________________________________ Address _________________________________ City, State, Zip Code _________________________________ Telephone