Disclaimer


I,________________________________________________ (DISCLAIMANT), do hereby irrevocably disclaim, renounce, waive and release, without qualification, all of my individual rights and Interests, and any Income from, as the primary individual beneficiary of the United States Social Security, Social Security number 012-34-5678, effective immediately.

I am also returning my Social Security card (enclosed) since it is now of no use to me, as without a beneficiary, the SS trust # 012-34-5678 has been terminated.


__________________________________________________ _______
(DISCLAIMANT OR DISCLAIMANT’S LEGAL REPRESENTATIVE)


THE STATE OF ________________

COUNTY OF __________________

This instrument was acknowledged before me on the _______ day of _____________, 20___ by DISCLAIMANT OR DISCLAIMANT’S LEGAL REPRESENTATIVE.

MY COMMISSION EXPIRES:_______________

_______________________________
Notary Public in and for the

State of ____________________
















Disclaimer


I, _______________________________________________ (DISCLAIMANT), do hereby irrevocably disclaim, renounce, and refuse to accept the interest in the following property, effective immediately, to which I might otherwise have been entitled, under the laws of the United States:

United States Social Security benefits, Social Security number 012-34-5678.


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.
I have not waived any right to disclaim*the property interest, and no guardian, conservator, or attorney-in-fact has executed such a waiver on my behalf. *I have not assigned, conveyed, encumbered, pledged, transferred, or otherwise disposed of my interest in the property disclaimed, and I have not entered into a*contract for the assignment, conveyance, encumbrance, pledge, transfer, or other disposition of that property. No sale or other disposition has been made pursuant to the judicial process.
It is my intention that this disclaimer and renunciation constitute a qualified disclaimer.

I am also returning my Social Security card (enclosed) since it is now of no use to me, as without a beneficiary, the SS trust # 012-34-5678 has been terminated.

__________________________________________________ _______
(DISCLAIMANT OR DISCLAIMANT’S LEGAL REPRESENTATIVE)


THE STATE OF ________________

COUNTY OF __________________

NOTARY PUBLIC
This instrument was acknowledged before me on the _______ day of _____________, 20___ by DISCLAIMANT OR DISCLAIMANT’S LEGAL REPRESENTATIVE.


MY COMMISSION EXPIRES:_______________

______________________________
Notary Public