HomeMy WebLinkAbout08-12-09 (2)QUALIFIED DISCLAIMER
In accordance with Internal Revenue Code Section 2518 (b) and pursuant to Section 6201 of the
Pennsylvania Probate Estate and Fiduciaries Code, (20 PA.C.S.A. Section 6201), this Qualified
Disclaimer is being executed by the undersigned beneficiary, Zachary J. Travis, in order to disclaim in
whole all of his interest in the Estate of Dorothy A. Travis, file number 21-09-0497.
The undersigned, as one of the beneficiaries in the above-referenced Estate, is hereby disclaiming
his interest in the Estate in favor of his father, David M. Travis, as evidenced by the undersigned's
execution hereof.
This disclaimer is executed as of this~bday of , 2009, the same being effective as
of the date of death of the decedent, Dorothy A. Travis on November 16, 2008.
WITNESS:
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STATE OF PENNSYLVANIA
COUNTY OF Cccmb~rl~~c
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On this, the ~~ day of 2009, before me, the undersigned
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officer, personally appeared Zachary J. Trav- is nown to me (or satisfactorily proven) to be the person
whose name is subscribed to the within instrument, and acknowledged that she executed the same for the
purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
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