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

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name:       Company:       Address:       City:       State:       Zip:       Phone:       Fax:       RENUNCIATION OF SUCCESSION – INDIVIDUAL (N.C. Gen. Stat. § 31-B) COMES NOW,       , as a party who has succeeded or will succeed to the following property interest,       and would state as follows: 1. The undersigned succeeded to said property interest as one of the following: Heir Next of kin Devisee Legatee Beneficiary of a life insurance policy who did not possess the incidents of ownership under the policy at the time of death of the insured Person succeeding to a renounced interest Beneficiary under a testamentary trust or under an inter vivos trust Appointee under a power of appointment exercised by a testamentary instrument or a non-testamentary instrument Surviving joint tenant, surviving tenant by the entireties, or surviving tenant of a tenancy with a right of survivorship Person entitled to share in a testator's estate under the provisions of G.S. 31- 5.5 Beneficiary under any other testamentary or nontestamentary instrument, including a beneficiary under: a. Any qualified or nonqualified deferred compensation, employee benefit, retirement or death benefit, plan, fund, annuity, contract, policy, program or instrument, either funded or unfunded, which is established or maintained to provide retirement income or death benefits or results in, or is intended to result in, deferral of income; b. An individual retirement account or individual retirement annuity; or c. Any annuity, payable on death, account, or other right to death benefits arising under contract The duly authorized or appointed guardian with the prior or subsequent approval of the clerk of superior court, or of the resident judge of the superior court, of any of the above. The personal representative appointed under Chapter 28A of any of the above, or the attorney-in-fact of any of the above. 2. The undersigned would by this notice hereby declare that: The undersigned completely renounces any and all rights of succession in the above described property interest, or The undersigned renounces the right to succeed to said property interest only in part, retaining the right of succession to the following property interest:       . 3. If the undersigned has elected to renounce a partial interest , the undersigned would further state that any instrument which may have created said interest does not contain a provision which would prohibit the renunciation of a fractional share of said property interest. 4. Pursuant to North Carolina Statute, this renunciation must be filed: (A) An instrument renouncing a present interest shall be filed within the time period required under the applicable federal statute for a renunciation to be given effect as a disclaimer for federal estate and gift tax purposes. If there is no such federal statute the instrument shall be filed not later than nine months after the date the transfer of the renounced interest to the renouncer was complete for the purpose of such taxes. (B) An instrument renouncing a future interest shall be filed not later than six months after the event by which the taker of the property or interest is finally ascertained and his interest indefeasibly vested and he is entitled to possession even though such renunciation may not be recognized as a disclaimer for federal estate tax purposes. 5. The undersigned gained a present property interest in the above described property on the       day of       , 20       , or The undersigned will gain an interest in the above-described property in the future. Said interest was finally ascertained and indefeasibly vested in the undersigned on the       day of       , 20       . This the       day of       , 20       . ___________________________ Signature of Renouncer Acknowledgment of Individual 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:       Certificate of Delivery I,       , hereby certify that I have delivered this day a true and correct copy of the foregoing to       by: Personal Delivery Mailing a true and correct copy of same by certified or registered U.S. mail, postage prepaid, return receipt requested. So certified this the       day of       , 20       . ________________________ Signature