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RENUNCIATION AND DISCLAIMER OF PROPERTY(INTESTATE SUCCESSION0 STATE OF CONNECTICUT COURT OF PROBATE Recorded: TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. IN THE MATTER OF (include all names and initials under which any asset was held)SOCIAL SECURITY NUMBER Hereinafter referred to as the decedent.DECEDENT’S RESIDENCE AT TIME OF DEATH (include full address) DATE OF DEATH PETITIONER (Name, address, zip code, and telephone number) RELATIONSHIP TO DECEDENT (if any) I. Pursuant to the General Statutes of Connecticut, Title 45, Chap. 802g, the undersigned, ______________________________ chooses to exercise his/her right to disclaim a partial interest or the entire interest in the described property. II. The decedent died intestate on the ______ day of1.__________________ , 20______ and the undersigned has an interest in the described property. III. Pursuant to intestate succession, the undersigned has an interest in the following property:________________________________________________________________________ IV. The undersigned attests that the disclaimer of the 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 Connecticut, 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 III. VI. 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______.Signature Type or Print Name State of Connecticut County of __________________The foregoing instrument was acknowledged before me this __________________ (date) by ______________________________ (name of person acknowledged).In witness whereof I hereunto set my hand. Date: ________________________Notary PublicMy commission expires: Type or Print NameI 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 Number Receipt of an executed copy of the above Renunciation and Disclaimer is acknowledged this ______ day of __________________, 20______.Signature Type or Print NamePersonal Representative/Executor/Executrix