Fill and Sign the Ohio Disclaimer Form

IN THE COURT OF       ___________________       DIVISION ________________ COUNTY, OHIO In Re the Estate of:       Name of the Deceased ) ) ) ) ) ) NO. _______________________ ) ) ) ) ) RENUNCIATION AND DISCLAIMER OF PROPERTY (Intestate Succession) I. Pursuant to the Ohio Revised Code, Title 13, Chapter 1339, the undersigned,       chooses to exercise his/her right to disclaim a partial interest or the entire interest in the described property. II. The decedent died intestate on             , 20       and the undersigned has an interest in the described property. III. Pursuant to intestate succession, the undersigned has an interest in the following property:       IV. The undersigned attests that the disclaimer of the property interest will be filed no later than nine months after the death of the decedent. - 1 - V. Pursuant to applicable law of the State of Ohio, 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 III. VI. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. 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) - 2 - STATE OF OHIO COUNTY OF       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 -