Fill and Sign the Tn Interest Form

IN THE PROBATE COURT OF ____________ COUNTY, TENNESSEE IN THE MATTER OF       DOCKET NO. ____________ DECEASED RENUNCIATION AND DISCLAIMER OF PROPERTY (Tenn. Code § 31-1-103) I. Pursuant to the Tennessee Code, § 31-1-103, the undersigned,       chooses to exercise his/her right to disclaim an interest in the real property which has devolved to him/her because of the death of the decedent. II. The decedent died on       ,       , 20       and the undersigned has an interest in the described real property. III. A description of the real property is as follows:       IV. The undersigned attests that the disclaimer of the real property interest will be filed no later than nine months after the death of the decedent. V. Pursuant to applicable law of the State of Tennessee and the Internal Revenue Code of 1986, if applicable, the undersigned hereby renounces and disclaims any interest or right to the real of the deceased described in paragraph III. Renunciation and Disclaimer of Property Page 1 of 3 VI. The real 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. A copy of the disclaimer shall be recorded in the office of the county clerk and recorder of the county in which the property or interest disclaimed is located. DATED this ______ day of ____________ , 20 ______ . Signature       STATE OF TENNESSEE COUNTY OF ____________ On this ______ day of ____________ , 20 ______ , before me personally appeared ______________________________ , to me known to be the person (or persons) described in and who executed the foregoing instrument, and acknowledged that such person (or persons) executed the same as such person (or person's) free act and deed. Notary Public       Type or Print Name Commission expires: __________________ Renunciation and Disclaimer of Property Page 2 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 Signature       Type or Print Name       Street Address       City, State and Zip Code       Telephone Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of __________________ , 20 ______ . Signature Signature Type Name:       [Personal Representative/Executor/Executrix] Renunciation and Disclaimer of Property Page 3 of 3