Fill and Sign the Nebraska Renunciation Form

RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) I. Pursuant to the Nebraska Revised Statutes, Chapter 39, 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. IV. - 1 - 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 Nebraska, 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) STATE OF NEBRASKA COUNTY OF       - 2 - The foregoing instrument was acknowledged before me this       (date) by       (name of person acknowledged). _________________________________ Notary Public Printed 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 -