SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ DIS _________ (Lined with:______________) In re Estate of ________________________________ CERTIFICATE OF FILING DISCLAIMER I, __________________________, hereby certify that on ______ day of ________________________, 20_____, I submit for filing the disclaimer of: NAME: _______________________________________________ ADDRESS: _______________________________________________ _______________________________________________ TELEPHONE #: __________________________________________ who disclaims an interest in the assets of ___________________________. Case No: _____ADM/SEB/TRP______ is open or is being opened. No case relating to this disclaimer has been opened in the Probate Division. Name: _______________________ Signature: _______________________ Address: _______________________ _______________________ _______________________ Tel. No.: ______________________________ June 2009 American LegalNet, Inc. www.FormsWorkFlow.com