Fill and Sign the Ny Property Form

Renunciation and Disclaimer of Property Page 1 of 4 SURROGATE’S COURT OF THE STATE OF NEW YORKCOUNTY OF ---------------------------------------------------------------------------Estate ofRENUNCIATION AND DISCLAIMER OF PROPERTY ,(Life Insurance or AnnuityContract)Deceased.File No. --------------------------------------------------------------------------- I. Pursuant to the New York State Consolidated Laws, Chapter 17-B, Article 2, Part 1, § 2-1.11, 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. Renunciation and Disclaimer of Property Page 2 of 4 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 New York State, 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______.Signature Type or Print Name Renunciation and Disclaimer of Property Page 3 of 4 STATE OF NEW YORKCOUNTY OF __________________ On the ______ day of __________________ in the year 20______ before me, the undersigned, personally appeared ______________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity (ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. Notary PublicMy commission expires: Type or Print NameI 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 of Party Printed Name Address City, State, and Zip Telephone Number Renunciation and Disclaimer of Property Page 4 of 4 Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of __________________, 20______.Signature Type or Print NamePersonal Representative/Executor/Executrix Affidavit in Relation to Renunciation and Disclaimer of Property Page 1 of 1 SURROGATE’S COURT OF THE STATE OF NEW YORKCOUNTY OF ---------------------------------------------------------------------------Estate ofAFFIDAVIT IN RELATION TO RENUNCIATION AND DISCLAIMER OF PROPERTY ,(Life Insurance or AnnuityContract)Deceased.File No. ---------------------------------------------------------------------------STATE OF NEW YORK ) ) ss.: COUNTY OF )I, , being duly sworn, depose and say:(1)My domicile is (Street Address) (City/Town/Village) (County) (State)(Zip) (Telephone Number) My mailing address is (If different from domicile) (2) Pursuant to § 2-1.11(b)(2), I hereby affirmatively state that I have not received and I am not to receive any consideration in money or money’s worth for the attached Renunciation from a person or persons whose interest is to be accelerated, unless payment has been authorized by the Court. Signature of Affiant Print Name Sworn to before me on __________________, 20______Notary Public