Fill and Sign the Surviving Joint Tenant with Right of Survivorship Chooses to Exercise Hisher Right to Disclaim Any Form

-1- RENUNCIATION AND DISCLAIMER OF JOINT TENANT INTEREST(Entire Interest of Joint Tenant) I. Pursuant to the South Dakota Codified Laws, Title 29A, Part 8, the undersigned, , the surviving joint tenant with right of survivorship, chooses to exercise his/her right to disclaim any and all interests he/ she may have in any property or interest that is the subject of a joint tenancy devolving to him/her because of the death of the decedent. II. The undersigned, as the surviving joint tenant, has an interest in the property 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. IV. As a joint tenant with right of survivorship, the undersigned has an interest in the following property: V. Pursuant to applicable law of the State of South Dakota, 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. -2- 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) -3- STATE OF SOUTH DAKOTA COUNTY OF On this day of , in the year , before me personally appeared , known to me (or proved to me on the oath of ) to be the person who is described in, and who executed the within instrument and acknowledged to me that he/she/they executed the same. 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 -4- Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this day of , 20 . (Name) Personal Representative/Executor/Executrix