Fill and Sign the Pa Disclaimer Form

Prepared by U.S. Legal Forms, Inc. Copyright 2016 - U.S. Legal Forms, Inc. STATE OF PENNSYLVANIA Renunciation And Disclaimer of Property (Life Insurance Or Annuity Contract) Control Number – PA - 03 - 03 NOTES ON COMPLETING THESE FORMS The form(s) in this packet contain “form fields” created using Microsoft Word. “Form fields” facilitate completion of the forms using your computer. They do not limit you ability to print the form “in blank” and complete with a typewriter or by hand. It is also helpful to be able to see the location of the form fields. Go to the View menu, click on Toolbars, and then select Forms. This will open the forms toolbar. Look for the button on the forms toolbar that resembles a “shaded letter “a”. Click in this button and the form fields will be visible. By clicking on the appropriate form field, you will be able to enter the needed information. In some instances the form field and the line will disappear after information is entered. In other cases it will not. This is appropriate and the way the form is designed to function. DISCLAIMER These materials were developed by U.S. Legal Forms, Inc. based upon statutes and forms for the State of Pennsylvania. All Information and Forms are subject to this Disclaimer: All forms in this package are provided without any warranty, express or implied, as to their legal effect and completeness. Please use at your own risk. If you have a serious legal problem we suggest that you consult an attorney. U.S. Legal Forms, Inc. does not provide legal advice. The products offered by U.S. Legal Forms (USLF) are not a substitute for the advice of an attorney. THESE MATERIALS ARE PROVIDED "AS IS" WITHOUT ANY EXPRESS OR IMPLIED WARRANTY OF ANY KIND INCLUDING WARRANTIES OF MERCHANTABILITY, NONINFRINGEMENT OF INTELLECTUAL PROPERTY, OR FITNESS FOR ANY PARTICULAR PURPOSE. IN NO EVENT SHALL U. S. LEGAL FORMS, INC. OR ITS AGENTS OR OFFICERS BE LIABLE FOR ANY DAMAGES WHATSOEVER (INCLUDING, WITHOUT LIMITATION DAMAGES FOR LOSS OF PROFITS, BUSINESS INTERRUPTION, LOSS OF INFORMATION) ARISING OUT OF THE USE OF OR INABILITY TO USE THE MATERIALS, EVEN IF U.S. LEGAL FORMS, INC. HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. In Re: : IN THE COURT OF COMMON PLEAS OF : ____________ COUNTY, PENNSYLVANIA : Deceased : : ORPHANS’ COURT DIVISION : : FILE NO.: ____________ RENUNCIATION AND DISCLAIMER OF PROPERTY (Life Insurance or Annuity Contract) I. Pursuant to the Pennsylvania Code, Title 20, Chapter 62, 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. As a result of this renunciation and disclaimer the following individual(s) will take the interest or right to inherit the property or asset of the deceased as described in paragraph IV: ____________________________________ ____________________________________ ____________________________________ VI. Pursuant to Pennsylvania Code, Title 20, Chapter 62, and the Internal Revenue Code of 1986, if applicable, the undersigned hereby renounces and disclaims any interest or right to the property or asset 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 ______ . Signature       Type or Print Name Personal Representative/Executor/Executrix STATE OF PENNSYLVANIA COUNTY OF __________________ On this, the ______ day of __________________ , 20 ______ , before me ____________________________________ , the undersigned officer, personally appeared ____________________________________ , known to me (or satisfactorily proven) to be the person whose name ______________________________ subscribed to the within instrument, and acknowledged that he / she executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal. Signature       Title of Officer My commission expires:       Type or Print Name 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       Type or Print Name Address       City, State, Zip Code Telephone 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 insurance company or other obligor of the decedent. DATED this ______ day of ____________ , 20 ______ . Signature       Type or Print Name Address       City, State, Zip Code Telephone 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 person entitled to the interest as a result of this disclaimer. DATED this ______ day of ____________ , 20 ______ . Signature       Type or Print Name Address       City, State, Zip Code Telephone