PERSON TO ACT AS EXECUTOR AND TRUSTEE

The following are additional instructions to be applied to the trust agreement established on ________________ (Date) by ________________________________, naming ______________________________________________________________ as beneficiary:

This being my last will and testament, I hereby designate ________________________ of _________________________________________________________________ (Address) to act as both executor and trustee of my estate.

______________________________ ______________________________

Signature Date

______________________________ ______________________________

Witness Date

______________________________ ______________________________

Witness Date

______________________________ ______________________________

Witness Date