Beneficiary Deed

 Request Form

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Grantor(s)/Owner(s) Full Legal Name(s):

__________________________________________________________________

__________________________________________________________________

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

__________________________________________________________________

__________________________________________________________________

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

Percentage Ownership (if not stated will be equal):

___________________________________________________________  ____%

___________________________________________________________  ____%

___________________________________________________________  ____%

___________________________________________________________  ____%

___________________________________________________________  ____%

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

_________________________________________________________________

_________________________________________________________________

.

If Grantee/Beneficiary should predecease the Grantor (see Information #3):

     (a) no LDPS  _______

     (b) LDPS _______

.

Form of Ownership To Be Held By Grantees/Beneficiaries (see Information #4):

     (a) Joint Tenants With Right of Survivorship  _______

     (b) Tenants In Common _______

.

(remember to include a copy of the current deed for such real property)

Missouri County Where Real Property is Located:

______________________________________________________________

Missouri City Where Real Property is Located:

______________________________________________________________

Address of Real Property:

Your Full Name:

______________________________________________________________

Your Mailing Address:

______________________________________________________________

______________________________________________________________

Your Telephone Number:

_______________________________________________________

Your Signature:

_______________________________________________________

Signatures of all Grantors/Owners:

______________________________________________________________

______________________________________________________________

.

By signing above you agree this form will serve as the written agreement between yourself and Michael J. Denk, Attorney at Law, to draft and provide you with one (1) Beneficiary Deed per your request and information as set forth on this form. The cost is $145.00 per deed. The filing/recording of your Beneficiary Deed and the filing fee as charged by the appropriate Recorder of Deeds office will be your responsibility. You understand and agree no legal advice is being provided to you and you should consult with an Attorney of your choice for such advice. You hereby release Michael J. Denk and Missouri Beneficiary Deed, LLC from any and all claims relating to your use of such Beneficiary Deed. If you have any questions or concerns please contact us prior to signing and returning this form. Thank you.

Fill in all information on this form and mail with payment and a copy of

the current deed for such real property to:

 Missouri Beneficiary Deed c/o

 Michael J. Denk, Attorney at Law

 P.O. Box 6464, Chesterfield, MO 63006