Fill and Sign the Oregon Judicial Department Probate Programs Ampamp Services State of Form

Renunciation and Disclaimer of Property Page 1 of 3 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY PROBATE DEPARTMENT In the Matter of the Estate of: ) )Case No.: ) ) Deceased ) RENUNCIATION AND DISCLAIMER OF PROPERTY I. Pursuant to the Oregon Revised Statutes, Chapter 105, the undersigned, , chooses to exercise his/her right to disclaim a partial interest or the entire interest in the described property. II. The undersigned has an interest in the property in the above-captioned estate of (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. Pursuant to the provisions of paragraph of decedent's last will and testamentdated (the "Will"), is entitled to receive the following property: V. Pursuant to applicable law of the State of Oregon, 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. VI. The property devolves to others pursuant to the provisions of applicable State law as though the undersigned had predeceased the decedent. Renunciation and Disclaimer of Property Page 2 of 3 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 Estate of to be filed with the court in the above-captioned proceeding. DATED this ______ day of ____________, 20______.Signature Type or Print NameSTATE OF OREGONCOUNTY OF __________________ The foregoing instrument was acknowledged before me this (date) by (name of person acknowledged.) Notary PublicMy commission expires: Type or Print Name Renunciation and Disclaimer of Property Page 3 of 3 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 of Party Printed Name Address City, State, and Zip Telephone NumberReceipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of __________________, 20______.Signature Type or Print NamePersonal Representative/Executor/Executrix