Disclaimer and Renunciation of Interest (Qualified Disclaimer) — Pennsylvania

TIMING — IRC § 2518 (9-MONTH DEADLINE): To qualify as a federal "qualified disclaimer," this writing must be signed and delivered within nine (9) months after the date of the decedent's death or other transfer (or within 9 months after the disclaimant turns 21), with no acceptance of the interest or its benefits. Pennsylvania's disclaimer statute (20 Pa.C.S. §§ 6201–6207) does not impose its own state-law deadline, but missing the federal 9-month window forfeits qualified-disclaimer (tax) treatment. Verify the deadline with counsel before signing.

DISCLAIMER AND RENUNCIATION OF INTEREST (QUALIFIED DISCLAIMER)

COMMONWEALTH OF PENNSYLVANIA

TABLE OF CONTENTS

1. Disclaimant Information
2. Identification of the Transfer and Interest Disclaimed
3. Statutory Authority
4. The Disclaimer
5. Qualified-Disclaimer Representations
6. Effect and Passing of the Disclaimed Interest
7. Irrevocability and Binding Effect
8. Filing, Delivery, and Recording
9. Signature, Acknowledgment, and Notarization
10. Verification / Declaration
11. Certificate of Delivery / Service
12. Attachments Checklist

1. DISCLAIMANT INFORMATION

The undersigned (the "Disclaimant") is a person to whom an interest in property would have devolved by whatever means within the meaning of 20 Pa.C.S. § 6201, namely a(n): ☐ beneficiary under a will ☐ appointee under the exercise of a power of appointment ☐ person entitled to take by intestacy ☐ joint tenant with right of survivorship ☐ donee of an inter vivos transfer ☐ donee under a third-party beneficiary contract (life insurance, annuity, or pension/profit-sharing/employee benefit plan) ☐ person entitled to a disclaimed interest ☐ other: [____________________].

2. IDENTIFICATION OF THE TRANSFER AND INTEREST DISCLAIMED

Source of the interest (check all that apply):
☐ Last Will and Testament of the Decedent
☐ Intestate succession (20 Pa.C.S. Ch. 21)
☐ Revocable, testamentary, or inter vivos trust
☐ Third-party beneficiary contract (life insurance, annuity, or pension/profit-sharing/employee benefit plan)
☐ Joint tenancy with right of survivorship
☐ Power of appointment
☐ Other: [________________________________]

Extent of the disclaimer:
☐ Full disclaimer — the Disclaimant disclaims the entire interest described above.
☐ Partial disclaimer — the Disclaimant disclaims only the following fractional, percentage, or pecuniary portion (a disclaimer may be made in whole or in part under 20 Pa.C.S. § 6203): [____________________] (e.g., an undivided ____% interest, or the sum of $[____________]).

Legal description of any real property disclaimed (or see attached Exhibit A): [________________________________]

3. STATUTORY AUTHORITY

This Disclaimer is made under Chapter 62 of the Pennsylvania Probate, Estates and Fiduciaries Code, 20 Pa.C.S. §§ 6201 through 6207, and is intended to constitute a qualified disclaimer under 26 U.S.C. § 2518 and Treas. Reg. § 25.2518-2.

• 20 Pa.C.S. § 6201 authorizes a person to whom an interest in property would have devolved by whatever means to disclaim it in whole or in part by a written disclaimer that (1) describes the interest disclaimed; (2) declares the disclaimer and the extent thereof; and (3) is signed by the disclaimant. The right to disclaim exists notwithstanding any spendthrift provision or similar restriction.
• 20 Pa.C.S. § 6203 provides that a disclaimer may be made of any present or future interest, vested or contingent, including a possible future right to take as an appointee under an unexercised power of appointment or under a discretionary power to distribute income or principal.
• 20 Pa.C.S. § 6204 governs the filing, delivery, and recording of the disclaimer (see Section 8).

4. THE DISCLAIMER

The Disclaimant, intending to be legally bound, hereby IRREVOCABLY DISCLAIMS and RENOUNCES all (or, where a partial disclaimer is elected in Section 2, the stated fractional, percentage, or pecuniary part of all) right, title, claim, and interest of every kind — whether vested or contingent, present or future, legal or equitable — in and to the property and interest described in Section 2 above.

This Disclaimer is made freely, voluntarily, and with full knowledge of its legal and tax consequences.

5. QUALIFIED-DISCLAIMER REPRESENTATIONS

The Disclaimant represents and certifies that:

☐ This Disclaimer is in writing and signed by the Disclaimant (or the Disclaimant's fiduciary or agent under 20 Pa.C.S. § 6202), and describes the interest disclaimed and declares the disclaimer and its extent, as required by 20 Pa.C.S. § 6201 and Treas. Reg. § 25.2518-2(b).

☐ This Disclaimer is being filed and delivered within nine (9) months after the later of (a) the date of the Decedent's death or the effective date of the transfer creating the interest, or (b) the date the Disclaimant attained age 21 (26 U.S.C. § 2518(b)(2)).

☐ The Disclaimant has NOT accepted the disclaimed interest or any of its benefits, and has not assigned, conveyed, encumbered, pledged, transferred, or contracted to transfer the interest (20 Pa.C.S. § 6206; Treas. Reg. § 25.2518-2(d)).

☐ The disclaimed interest passes without any direction on the part of the Disclaimant (26 U.S.C. § 2518(b)(4); Treas. Reg. § 25.2518-2(e)).

☐ As a result of this Disclaimer, the interest passes to the person(s) entitled to take as if the Disclaimant had died before the Decedent or the inter vivos transfer, as provided by 20 Pa.C.S. § 6205.

6. EFFECT AND PASSING OF THE DISCLAIMED INTEREST

Under 20 Pa.C.S. § 6205, this Disclaimer relates back to the date of the Decedent's death or the date of the inter vivos transfer, as the case may be. The disclaimed interest passes as if the Disclaimant had died immediately before that date. The Disclaimer shall not diminish the rights of any person other than the Disclaimant under the instrument of transfer or applicable intestate law, and shall not diminish the rights of the Disclaimant other than in the interest disclaimed.

The Disclaimant does not direct to whom the disclaimed interest passes; it passes solely by operation of the governing instrument, the Decedent's will, or Pennsylvania law.

7. IRREVOCABILITY AND BINDING EFFECT

This Disclaimer is irrevocable and may not be modified, withdrawn, or rescinded once filed and delivered as provided in 20 Pa.C.S. § 6204. It is binding upon the Disclaimant and all persons claiming through or under the Disclaimant.

8. FILING, DELIVERY, AND RECORDING

Pursuant to 20 Pa.C.S. § 6204, the Disclaimant shall (check all that apply):

☐ File this Disclaimer with the Clerk of the Orphans' Court Division of [____________] County, Pennsylvania — the county where the Decedent died domiciled (or, if the Decedent was not domiciled in the Commonwealth, the county where the property is located) — and deliver a copy to any personal representative, trustee, or other fiduciary in possession of the property (interest devolving by will or intestacy) (§ 6204(a)).

☐ Deliver this Disclaimer or a copy to the trustee or other person having legal title to or possession of the property, or who is entitled to it by reason of the disclaimer (interest devolving by an inter vivos instrument) (§ 6204(b)).

☐ Deliver this Disclaimer or a copy to the insurance company, employer, or other obligor, and to the person entitled to the interest by reason of the disclaimer (interest devolving by a third-party beneficiary contract) (§ 6204(b.1)).

☐ File or deliver this Disclaimer as required by the above provisions where the interest would have devolved by reason of the exercise of a power of appointment (§ 6204(c)).

☐ Record a copy of this Disclaimer in the Office for the Recording of Deeds of [____________] County, Pennsylvania, where any disclaimed real estate is situated. Under § 6204(d), the disclaimer is not effective as to a bona fide grantee or lienholder who has given value before the disclaimer is recorded.

9. SIGNATURE, ACKNOWLEDGMENT, AND NOTARIZATION

Executed this [____] day of [____________], 20[____].

Disclaimant Signature: ______________________________________

Printed Name: [________________________________]

ACKNOWLEDGMENT

COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF [____________] )

On this [____] day of [____________], 20[____], before me, the undersigned officer, personally appeared [DISCLAIMANT FULL LEGAL NAME], known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained.

In witness whereof I hereunto set my hand and official seal.

______________________________________
Notary Public — Commonwealth of Pennsylvania
My commission expires: [__/__/____]

[NOTARY SEAL]

10. VERIFICATION / DECLARATION

I, [DISCLAIMANT FULL LEGAL NAME], verify that the statements made in the foregoing Disclaimer are true and correct, that I have not accepted the disclaimed interest or any benefit thereof, and that I make this Disclaimer of my own free will. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.

Signature: ______________________________________
Date: [__/__/____]

11. CERTIFICATE OF DELIVERY / SERVICE

I certify that on the date(s) shown below a true and correct copy of this Disclaimer was delivered (in person, or by mail) to the following:

Signature: ______________________________________
Printed Name: [________________________________]

12. ATTACHMENTS CHECKLIST

☐ Copy of the Last Will and Testament, trust instrument, or beneficiary designation creating the disclaimed interest
☐ Exhibit A — legal description of any real property disclaimed
☐ Certified copy of the Decedent's Death Certificate
☐ Proof of delivery / mailing (certified mail receipts)
☐ Copy of the recorded Disclaimer (Recorder of Deeds), if real property is involved
☐ Time-stamped copy from the Clerk of the Orphans' Court Division
☐ Court order authorizing disclaimer by a fiduciary or agent, if applicable (20 Pa.C.S. § 6202)

SOURCES AND REFERENCES

• Pennsylvania Disclaimers, 20 Pa.C.S. Ch. 62 (§§ 6201–6207) — https://www.legis.state.pa.us/WU01/LI/LI/CT/HTM/20/00.062..HTM
• 20 Pa.C.S. § 6204 (Filing, delivery and recording) — https://govt.westlaw.com/pac/Document/NA5841E10342E11DA8A989F4EECDB8638
• 26 U.S.C. § 2518 (Disclaimers) — https://www.law.cornell.edu/uscode/text/26/2518
• Treas. Reg. § 25.2518-2 (Requirements for a qualified disclaimer) — https://www.law.cornell.edu/cfr/text/26/25.2518-2