Missouri Beneficiary Deed™Request Form

Grantor(s) Mailing Address (no P.O. Boxes)

_____________________________________________________________________________

_____________________________________________________________________________

Grantee(s)/Beneficiary(ies) Full Legal Name(s)

Percentage Ownership (if not stated will be equal)

Relationship to the Grantor(s)/Owner(s)

____________________________________________________________________    ______%

Name of Grantee/Beneficiary

____________________________________________

Relationship to Grantor(s)/Owner(s)

____________________________________________________________________    ______%

Name of Grantee/Beneficiary

_____________________________________________

Relationship to Grantor(s)/Owner(s)

____________________________________________________________________    ______%

Name of Grantee/Beneficiary

_____________________________________________

Relationship to Grantor(s)/Owner(s)

____________________________________________________________________    ______%

Name of Grantee/Beneficiary

_____________________________________________

Relationship to Grantor(s)/Owner(s)

Mailing Address of one Grantee (no P.O. Boxes)

_____________________________________________________________________________

_____________________________________________________________________________

If a Grantee/Beneficiary should predecease the Grantor

 (for explanation see #3 and #4 on Information Page)

   (a) No LDPS  _______

     (b) LDPS _______

Form of Ownership to be held by Grantees/Beneficiaries

         (for explanation see #5 on Information Page)

      (a) Joint Tenants with Right of Survivorship _______

       (b) Tenants in Common _______

Missouri County where the Real Property is located

___________________________________________________________________________

Address of Real Property

___________________________________________________________

___________________________________________________________

Your Full Name and Relationship to Owner(s)

___________________________________________________________________________

Your Mailing Address

___________________________________________________________________________

___________________________________________________________________________

Your Telephone Number

___________________________________________________________________________

Your Signature*

___________________________________________________________________________

Signatures of all Grantors/Owners*

___________________________________________________________________________

___________________________________________________________________________

*(by signing this form you acknowledge and agree to the Important Notes below)

IMPORTANT NOTES*

1. By signing this form you agree this form will serve as the written agreement between yourself and Michael J. Denk, Attorney at Law and Missouri Beneficiary Deed, LLC, to draft and provide you with one (1) Missouri Beneficiary Deed (at the cost of $195) per your request and based upon the information you provide on this form. You understand and agree no other drafting services are being provided to you.

2. The signing and proper recording of your Missouri Beneficiary Deed and the fee charged by the local County Recorder of Deeds office to record such deed will be and is YOUR responsibility.

3. You understand and agree no legal advice is being provided to you and you should consult with an Attorney of your choice for such legal advice.

4. In your behalf and on behalf of your estate you hereby release and hold harmless Michael J. Denk, Attorney at Law and Missouri Beneficiary Deed, LLC, from any and all claims relating to your use and implementation of such Missouri Beneficiary Deed.