# Peerage Act 1963, 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
Signed and sealed by the said in the presence of:
Signature of witness
(L.S.) Signature
Address
Description
Annex
Description of peerage[s]
Date[s]of succession

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Source: https://www.legislation.gov.uk/ukpga/1963/48/schedule/1/paragraph/1 (the official version)
Page: https://openlegislation.uk/peerage-act-1963/schedule-1/paragraph-1
Contains public sector information licensed under the Open Government Licence v3.0. Source: legislation.gov.uk, The National Archives.