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

RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) I. Pursuant to the North Carolina General Statutes, Chapter 31B, 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 six months after the death of the decedent. 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 North Carolina, 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 NORTH CAROLINA COUNTY OF _____________________ I, a Notary Public, do hereby certify that _________________________________ (here give the name of the grantor or maker) personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and (where an official seal is required by law) official seal This the ___________________ day of ___________________ (year). (Official seal.) ______________________________ Notary Public Printed 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