Disclaimer Of Interest Under Will

WHEREAS, I, of [ADDRESS], declare that I am a beneficiary under the Last Will and Testament (hereinafter the "Will") of [NAME OF DECEDENT] dated [DATE]; and

WHEREAS, on [DATE], the said [NAME OF DECEDENT] died; and

WHEREAS, on the [DATE], the Will was admitted to probate in the District of .............; and

WHEREAS, pursuant to Paragraph ... of ARTICLE ....... of the Will, I am a discretionary beneficiary of a trust to be held in accordance with the terms of ARTICLE ......... of the Will (hereinafter the "Trust"); and

WHEREAS, pursuant to Paragraph ... of ARTICLE ..... of the Will, I am nominated and appointed, with [NAME OF CO-TRUSTEE], as Trustee of the Trust; and

WHEREAS, pursuant to subparagraph ... of Paragraph ... of ARTICLE ........, I, as Trustee, am given certain discretionary powers to pay or apply net income or principal to or for a certain class of persons, in such amounts and proportions as the said [NAME OF CO-TRUSTEE] and I, as Trustees may determine.

NOW, THEREFORE, I hereby disclaim, renounce and refuse to accept the following interests in property granted to me under the Will and Trust:

ARTICLE #

1. Paragraph ... of ... ARTICLE ......

2. Paragraph ... of ... ARTICLE ......

DESCRIPTION OF INTEREST

Discretionary income and principal beneficiary of the ............. Trust created pursuant to the terms of said ARTICLE. Any and all discretionary powers to allocate income or principal among beneficiaries which I would otherwise have as Trustee of the Trust pursuant to the terms of said Paragraph ... (but not my right to be a trustee, and not other powers as a trustee of the Trust).

I affirm that I have not accepted any interest in or benefit from the property interest hereby disclaimed and renounced, and that I have not received and I will not receive any consideration in money or money's worth for making this disclaimer and renunciation.

It is my intention that this disclaimer and renunciation constitute a qualified disclaimer as defined in Section 2518(c)(3) of the Internal Revenue Code, as amended, or the corresponding provisions of any subsequent federal tax law.

In witness whereof, I have herein to set my hand and seal this .....

day of [MONTH], 20...

Signed, sealed and delivered in our presence:

WITNESSES:

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Print Name:

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