Disclaimer Inheritance Form – Fill Out and Use This PDF

AFFIDAVIT OF DISCLAIMER OF INTEREST BY HEIR OF

TANADGUSIX CORPORATION SHAREHOLDER

[AS 13.12.801]

STATE OF _____________________)

___________ JUDICIAL DISTRICT : ss.

or COUNTY OF _________________)

I, ________________________________, swear upon my oath or affirm under

(print full legal name)

penalty of perjury, that to the best of my knowledge, information and belief:

1._________________________ (“Decedent”) died on ___________________,

as shown by the attached certified copy of the Decedent’s Death Certificate.

2.Decedent owned ______________ shares of Settlement Common Stock

(number)

(“Stock”) in Tanadgusix Corporation.

3.I am the _________________________________________ of the Decedent

(relationship to Decedent)

and may have a present or prospective interest in the Stock which was owned by the Decedent.

4.Pursuant to AS 13.12.801, I hereby disclaim any and all interest in the Stock owned by the Decedent.

I agree to defend, indemnify and hold Tanadgusix Corporation harmless from any claims, demands, fees or expenses that result in any way from the Tanadgusix Corporation's reliance upon this Affidavit.

DATED at _________________________, on this ____ day of ___________, 20___.

(city, state)

AFFIANT:

Signature:______________________________________________

(sign full legal name in presence of notary public)

Name (please print):_______________________________

Address:_______________________________________

_______________________________________

Telephone No.:_________________________________

SUBSCRIBED AND SWORN TO OR AFFIRMED UPON PENALTY OF PERJURY before me, this

_____ day of _________________, 20___.

______________________________________

Notary Public in and for _____________

My Commission Expires:________________