C.R.S. § 15-22-111

REVOCATION

OF DESIGNATED BENEFICIARY AGREEMENT

I __________ (insert your full name), reside at __________ (insert your current address) and I entered into a designated beneficiary agreement on __________ (insert the date) with the following person __________ (insert the other person's name) whose last-known address is __________ in which I designated such person as a designated beneficiary. This designated beneficiary agreement was recorded on __________ (insert the date) in the county of __________. The indexing file number of the designated beneficiary agreement is __________. I hereby revoke that designated beneficiary agreement, effective on the date and time that this revocation is received for recording by the clerk and recorder of __________ county. ________________ __________ Name Date STATE OF COLORADO County of __________ This document was subscribed, sworn to, and acknowledged before me on __________ date by __________ My commission expires __________ [Seal] __________________________ Notary Public This revocation of beneficiary agreement was recorded in my office on,, at o'clock, and, pursuant to section 15-22-111, Colorado Revised Statutes, I mailed a copy of this revocation of beneficiary agreement to at the address contained in this revocation of beneficiary agreement. Clerk and Recorder of __________ County By: __________