SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION ______ DIS ______ (Link to ______________) In re Estate of ______________________________ CERTIFICATE OF FILING DISCLAIMER I, ____________________________________, hereby certify that on the _______ day of _________________________, 20_____, I submit for filing the disclaimer of a. Name: b. Telephone number: c. Mailing address: _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ who disclaims an interest in the assets of _______________________________________. Choose one of the following: [ ] A case is open or is being opened. Case Caption: Case Number: [ ] _______________________________________ _______________________________________ No case relating to this disclaimer has been opened in the Probate Division. ___________________________________ Signature ___________________________________ Typed Name ___________________________________ Address (actual address/not Post Office Box) ___________________________________ ___________________________________ ___________________________________ Telephone number October 2012 ­ 700.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com ___________________________________ E-mail Address ___________________________________ Bar Number (if filer is an attorney) October 2012 ­ 700.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com