Model Disclaimer Form - Prudential

Model Qualified Disclaimer Form 

I,________________________________________________ (DISCLAIMANT), in 

accordance with the provisions of Section 2518 of the Internal Revenue Code and 

Section ___________ of the State of ______________________________ (INSERT 

NAME OF APPLICABLE LAW), do hereby irrevocably disclaim my interest in any and 

all property (OR A PARTIAL DISCLAIMER - ENTER THE PARTIAL AMOUNT, IF 

APPLICABLE) passing under Section ____ of the_ 

(NAME OF QUALIFIED PLAN) of___________________________________________ 

(NAME OF PARTICIPANT), deceased on ____________________________________ 

(DATE OF DEATH), said disclaimed property being more particularly described as 

follows: 

(DESCRIPTION OF QUALIFIED PLAN AND DEATH BENEFIT) 

___________________________________ 

(DISCLAIMANT OR DISCLAIMANT’S LEGAL 

REPRESENTATIVE) 

THE STATE OF ________________ 

COUNTY OF __________________ 

This instrument was acknowledged before me on the _______ day of 

_____________, 20___ by (DISCLAIMANT OR DISCLAIMANT’S LEGAL REPRESENTATIVE). 

_______________________________ 

Notary Public in and for the 

State of ____________________ 

I received this disclaimer on the ______ day of _____________________________, 20__. 

__________________________________ 

PLAN ADMINISTRATOR

Instructions for Model Qualified Disclaimer Form 

Important Notice: 

Qualified disclaimers are governed by the Internal Revenue Code and the applicable state 

probate code. The model qualified disclaimer form satisfies the requirements of the Internal 

Revenue Code, but may or may not meet all the requirements of state law. Special rules 

may apply when the disclaimant is a nonresident alien. Therefore, we recommend the 

disclaimant seek competent legal advice to ensure that all of the state’s requirements have 

been met. 

General Requirements: 

The disclaimant is the person who would have received the disclaimed death benefit under 

the qualified plan if the disclaimer had not been made. This may be a beneficiary who was 

specifically designated by the participant, or a beneficiary determined under the plan’s 

default beneficiary provisions. However, the disclaimant is not necessarily the person making 

the disclaimer. The disclaimer may be signed by the disclaimant’s legal representative. 

The disclaimant must not have expressly or implicitly accepted the benefit before making the 

disclaimer. The beneficiary of a qualified plan may disclaim any interest, in whole or in part. 

The disclaimer is irrevocable once made. 

The disclaimer must be made and delivered to the plan administrator within nine (9) months 

of the later of the participant’s date of death or nine (9) months after the date on which the 

disclaimant attains twenty-one (21) years of age. 

Effective January 1, 2003, for a disclaimer to be valid for purposes of the Internal Revenue 

Code section 401(a)(9) minimum required distribution purposes, it must be delivered to the 

plan administrator by September 30 of the calendar year following the year of the 

participant’s death. 

Next Steps: 

Please return the completed qualified disclaimer with a notarized signature within ___ days 

to: _______________________________________________ 

_______________________________________________ 

_______________________________________________ 

_______________________________________________

Model Disclaimer Form - Prudential

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