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.
__________________________
NameDate
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: __________
C.R.S. § 15-22-111