Paragraph 1

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