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SCHEDULE 1U.K. Form, Delivery, Certification and Registration of Instruments of Disclaimer

1U.K.An instrument of disclaimer under this Act shall be an instrument under seal in the following form or any form to the like effect:

Peerage Act 1963

Whereas I,, succeeded to the peerage[s] described in the Annex hereto on the date[s] specified in that Annex, and desire to disclaim the said peerage[s] for my life under the above mentioned Act;

And whereas I attained the age of 21 years [before the said date[s]] [on theday of];

Now therefore, I, the said,

in accordance with the provisions of the said Act, hereby disclaim the said peerage[s] for my life.

In witness whereof I have hereunto set my hand and seal thisday of

Signed and sealed by the said in the presence of:
Signature of witness (L.S.) Signature


Description of peerage[s]Date[s]of succession