The below form should work in all states:
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STATE OF _____________________)
___________ JUDICIAL DISTRICT : ss.
or COUNTY OF _________________)
AFFIDAVIT OF DISCLAIMER OF INTEREST BY HEIR
I, ________________________________, swear upon my oath or affirm under
(print full legal name)
penalty of perjury, that to the best of my knowledge, information and belief:
1. _________________________ (“Decedent”) died on ___________________,
as shown by the attached certified copy of the Decedent’s Death Certificate.
2. I am the legal heir and/or have been named as beneficiary of the estate of the decedent.
3. I am the ______ (relationship to Decedent)
and may have a present or prospective interest in estate of the decedent.
4. I hereby disclaim any and all interest in the estate of the decedent
I agree to defend, indemnify and hold all other heirs and/or beneficiaries harmless from any claims, demands, fees or expenses that result in any way from their reliance upon this Affidavit.
DATED at _________________________, on this ____ day of ___________, 20___.
(sign full legal name in presence of notary public)
Name (please print):_______________________________
SUBSCRIBED AND SWORN TO OR AFFIRMED UPON PENALTY OF PERJURY before me, this _____ day of _________________, 20___.
Notary Public in and for _____________
My Commission Expires:________________