Missouri Beneficiary Deed™Request

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 the 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*

___________________________________________________________________________

___________________________________________________________________________

(*Signatures Required - by signing this form you acknowledge

and agree to the Important Notes as set forth below.)

IMPORTANT NOTES*

1. By signing this form you agree this form will serve as the complete written agreement between yourself and Missouri Beneficiary Deed, LLC, to 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 request form.

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

3. You understand and agree no legal advice has been provided  to you and no legal services have been provided to you. Consult with an Attorney of your choice for legal advice and a review of your particular legal concerns and affairs.

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