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Qualified Personal Residence Trust Agreement

This Qualified Personal Residence Trust Agreement (Agreement) is executed in duplicate and is between [name], an individual residing at [address] (Settlor), and [name], an individual residing at [address] (Trustee).

The Settlor hereby transfers and assigns to the Trustee, certain property located at [street address, city and state] which property is identified in greater detail on Exhibit A, attached hereto and incorporated herein by this reference (Property). That property and all investments and reinvestments thereof and any property added to the trust in accordance with the provisions of this Agreement shall be held upon the following terms:

1. Trust is Irrevocable. This Agreement shall be irrevocable. Neither the Settlor nor any other person shall have the power to alter, amend, revoke or terminate this Agreement in part or in whole.

2. Rights During Income Term. During the period beginning on the date of this Agreement and ending on the first to occur of (a) the date that is [number] years after the date of this Agreement or (b) the Settlor's death (which period is hereinafter called the Income Term), the Trustee shall:

(i) Permit the Settlor to use and enjoy all residential and other property from time to time constituting property of this Trust, subject to the Trustee's powers of sale hereinafter set forth;

(ii) Pay to the Settlor or apply for the Settlor's benefit the entire net income of the trust, if any, in convenient installments, not less frequently than quarterly;

(iii) Pay to the Settlor cash to the extent required by this Agreement; and

(iv) At the Settlor's request, sell the then existing residence held by the trust and replace it in accordance with the provisions of this Agreement.

3. Termination Provisions. At the end of the Income Term, the Trustee shall (a) if the Income Term ends because of the Settlor's death, distribute the remaining net income, if any, and principal of the trust to the personal representative of the Settlor's probate estate, and administer and distribute the principal of the trust in accordance with Paragraph 4 of this Agreement; or (b) if the Income Term ends because the [number]- year period has run, distribute the remaining net income, if any, to the Settlor and administer and distribute the remaining principal of the trust in accordance with the provisions of Paragraph 4 of this Agreement.

4. Distribution of Trust Principal After Income Term. Any remaining principal of the trust available after termination of the Income Term, as provided in Paragraph 3(b), shall be administered and distributed under the provisions of this Paragraph 4.

(a) If the Settlor Survives. Following the termination of the Income Term pursuant to Paragraph 3(b), the Trustee shall continue to hold trust property under the provisions of this Agreement. During the lifetime of the Settlor, the Trustee shall, subject to the requirements of Paragraph 6(b) with respect to a fair rental, permit him to use, occupy and enjoy, any residence which may constitute part of the principal of the trust, whether such interest is held by the Trustee as owner, lessee, shareholder, trust beneficiary or otherwise and the Trustee shall not transfer, sell or lease its interest in the residence without the prior written consent of the Settlor so long as he is then legally competent.

(b) Transfer of Interest in Property or Any Subsequent Residence. Upon the written request of the Settlor, the Trustee shall sell, transfer or lease its interest in the Property or any subsequent residence acquired, upon such terms and conditions as the Trustee determines. If an interest in the Property or any subsequent residence is sold, the Trustee shall add the net proceeds of sale to the principal of the trust, and upon the written request of the Settlor shall purchase or construct another residence for him, the cost of which shall not exceed the net proceeds of sale received by the Trustee. Any residence acquired after the sale of the Property shall be held by the Trustee upon the same terms and conditions applicable to the Property under this Paragraph 4(b). All real estate taxes, casualty and liability insurance premiums, cost of repairs and other expenses incurred in operating and maintaining the Property or any subsequent residence shall be paid by the Settlor. Any unexpended income shall be annually accumulated and added to principal.

(c) Division of Trust. Upon the death of the Settlor, the Trustee shall continue to hold any remaining balance of any property managed under the provisions of this Agreement for the benefit of [name of relative and his relationship to settlor], if he is then living. If such person is not then living, any such property shall remain in trust until there are no living children of [name of settlor] under age twenty-one. Until then the Trustee shall pay to or expend for the benefit of any one or more of the children of [name of settlor], not necessarily in equal shares, as much of the income and principal of such portion as the Trustee considers advisable for the children's health, education and support in reasonable comfort. Any unexpended income shall be annually accumulated and added to principal. When there are no living children of [name of settlor] under age twenty-one, the balance of such portion, if any, shall be distributed outright and free of trust in the manner provided for in Paragraph 16(b) of this Agreement among the descendants of [name of settlor], or in the absence of such descendants, among the Settlor's descendants. However, any property distributable to a person for whom other property is then being held in trust under this Agreement, shall be added to such other trust property and thereafter administered and distributed under the terms of such trust.

5. Savings Clause and General Provisions. The trust is intended to qualify for the exception provided in Section 2702(a)(3)(A)(ii) of the Internal Revenue Code of 1986, as from time to time amended (Code), as a qualified personal residence trust under applicable Treasury Regulations (Regulations), and any provision of this Agreement inconsistent with this intention shall be of no force and effect. The Settlor specifically empowers the Trustee to amend the terms of this Agreement in any manner that may be required in order for this Agreement to comply with the requirements of Code Section 2702(a)(3)(A)(ii) and the Regulations promulgated thereunder, and any such amendment shall apply retroactively to the execution of this Agreement. Subject to the foregoing, the provisions of this paragraph shall apply for all purposes during the duration of the Income Terms of this Agreement:

(a) Distributions During Income Term. No distributions of income or principal may be made to anyone other than the Settlor prior to the expiration of the Income Term.

(b) Eligible Trust Property. The trust may not hold any asset other than one (1) residence to be used by the Settlor as a "personal residence" (within the meaning of applicable Regulations). Despite the foregoing, the Trustee may, subject to the following limitations, receive cash additions to the trust at any time, and the Trustee may hold additions of cash in a separate account. However, in no event may the total amount of cash in such account exceed the amount required:

(i) For payment of trust expenses (including mortgage payments) already incurred or reasonably expected to be incurred within six (6) months from the date the addition is made;

(ii) For improvements to the residence to be paid by the trust within six (6) months from the date such improvements are made;

(iii) For purchase by the trust of a residence to replace the Property, or any another residence, within three (3) months of the date the addition is made, provided the Trustee has previously entered into a contract to purchase that residence.

Any improvements to any residence held by the trust must meet the requirements of a personal residence.

(c) Proceeds of Sale. The Trustee may retain any proceeds from the sale of a personal residence held by the trust (including any income thereon) for a period not to exceed two years from the date of sale, or such other period of time as may be allowed by applicable Regulations, provided, the Trustee intends to use the proceeds within that period to purchase another residence to be used as a personal residence by the Settlor.

(d) Proceeds of Insurance. The Trustee may retain any proceeds of insurance paid to the trust as a result of damage to or destruction of a personal residence held by the trust for a years, or such other period of time as may be allowed by applicable Regulations, provided the Trustee intends to use the proceeds for repair, improvement or replacement of the personal residence.

(e) Damage or Destruction of Trust Property. If damage or destruction renders the personal residence held by the trust unusable as a residence, this Agreement shall cease to be a qualified personal residence trust on the date that is two (2) years after the date of damage or destruction (or the date of termination of Settlor's interest in the trust, if earlier) unless, prior to such date:

(i) Replacement of or repairs to the residence are completed;

or

(ii) A new residence is acquired by the trust.

(f) Cessation of Personal Residence Use. Except as otherwise provided in subparagraphs (b), (c), (d), and (e) of this paragraph, if, during the Income Term, a residence held by the trust ceases to be the Settlor's personal residence, the Trustee must within thirty (30) days either terminate this Agreement and distribute all remaining trust property outright to the Settlor; or administer the trust property for the balance of the Income Term as a separate share of the trust meeting all requirements of, and functioning exclusively as, a qualified annuity trust within the meaning of applicable Regulations, and commencing as of the earlier of:

(i) The date of receipt of the proceeds of the residence, or

(ii) The date of damage to or destruction of the residence, or

(iii) The cessation for the use of the residence as the

Settlor's personal residence.

(g) The election to convert the trust to a qualified annuity trust pursuant to subparagraph 5(f) may not be exercised by the Settlor if he is then serving as Trustee. In that event, the person designated as successor Trustee shall exercise such election.

(h) Qualified Annuity Trust. Should the Trustee elect to convert the trust to a qualified annuity trust pursuant to subparagraph (f) of this Paragraph, the Trustee shall:

(i) Pay the Settlor an "Annuity Amount" determined by dividing the value of all interests retained by the Settlor (as of the date of the original transfer), or the value of all the trust's property (as of the conversion date), whichever is less by an annuity factor determined for the remainder of the Income Term, and at the rate used in valuing the Settlor's interest at the time of the original transfer;

(ii) Pay the Annuity Amount in equal quarterly installments from income and, to the extent income is insufficient, from principal;

(iii) In determining the Annuity Amount, pro rate the Annuity Amount on a daily basis for short taxable years;

(iv) Add to principal any trust income not distributed to the Settlor as part of the Annuity Amount;

(v) If the initial net fair market value of the trust property is incorrectly determined, then within a reasonable period after the final determination of the correct value, the Trustee shall pay the Settlor in case of an under-valuation, or the Settlor shall pay the Trustee, in the case of an over-valuation, an amount equal to the difference between the Annuity Amount properly payable and the Annuity Amount actually paid plus interest on such amounts computed at the rate required by the applicable Regulations or, if there are no such Regulations, the rate used for valuing annuity interests under Code Section 664, compounded annually.

(i) Distribution to Settlor. Unless the Trustee elects to convert the trust to a qualified annuity trust pursuant to subparagraph (f) of this Paragraph, the Trustee shall distribute to the Settlor, at least quarter-annually, any cash in excess of the amounts permitted to be held by the Trustee under subparagraphs (b), (c), and (d) of this Paragraph or under applicable Regulations. In addition, upon termination of the Income Term, any amounts held by the Trustee pursuant to subparagraphs (b), (c), and (d) of this Paragraph that are not used to pay trust expenses shall be distributed outright to the Settlor within thirty (30) days of termination.

(j) Commutation Prohibited. In no event shall the Trustee commute the Settlor's interests in the trust.

(k) Cessation of Settlor's Use. If during the Income Term the residence held by this Agreement ceases to be used or held for use by the Settlor as the Settlor's personal residence, the trust shall cease to be a qualified personal residence trust.

6. Leasing of Qualified Personal Residence.

(a) During the Income Term, and subject to any restrictions now existing or hereafter promulgated pursuant to Code Section 2702(a)(3)(A)(ii) and the Regulations thereunder, including but not limited to Regulation Section 25.2702-5, or any other provision of the Code relating to qualified personal residence trusts, the Trustee may lease the Property or any other personal residence held by this trust to any party whom the Trustee deems advisable, for a term consistent with the requirements of Code Section 280A(d)(1), as may be amended from time to time, at a rate equal to the fair market rental value of the personal residence, and upon such other terms and conditions as the Trustee deems necessary.

(b) In addition to the powers of the Trustee set forth in Paragraph 6(a) above, upon the expiration of the Income Term, and subject to any restrictions now existing or hereafter promulgated pursuant to Code Section 2702(a)(3)(A)(ii) and the Regulations thereunder, including but not limited to Regulation Section 25.2702-5, or any other provision of the Code relating to qualified personal residence trusts, the Trustee shall, at the Settlor's request, lease the Property, or any other personal residence held by this Agreement to the Settlor for any term requested by the Settlor, at a rate equal to the then fair market rental value of the personal residence, and upon such other commercially reasonable terms and conditions as the parties may agree.

7. Facility of Payment. If at any time a beneficiary eligible to receive net income or principal distributions is under legal disability, or in the reasonable judgment of the Trustee is incapable of properly managing his financial affairs, then the Trustee may make those distributions for the benefit of the beneficiary, to a lawful guardian of the beneficiary, or to a custodian selected by the Trustee for the beneficiary under a Uniform Transfers to Minors Act or similar applicable law, or may otherwise expend the amounts to be distributed for the benefit of the beneficiary in such manner as the Trustee considers advisable.

8. Spendthrift Provision. To the extent permitted by law, no interest of any beneficiary in the income or principal of this Agreement or any separate portion of this Agreement shall be subject to pledge, assignment, sale or transfer in any manner, nor shall any beneficiary have the power in any manner to anticipate, charge or encumber his interest in trust income or principal, nor, while in the possession of the Trustee, shall such interest of any beneficiary be liable for, or in any manner subject to, the debts, contracts, liabilities or torts of any beneficiary.

9. Small Trust Termination. If at any time after the Income Term has ended, the Trustee shall determine that this Agreement or any portion thereof shall be so small that the expense of continuing such trust is in the Trustee's discretion unwarranted, the Trustee, without further responsibility, may (but need not) distribute the income and principal of the trust to the beneficiary for whom the trust is named. The interest of the beneficiary of the trust is expressly made subject to this power of the Trustee, and the Trustee shall have no liability to any beneficiary due to the exercise of this power.

10. Perpetuities Savings. Notwithstanding any other provision of this Agreement to the contrary, this Agreement or any portions hereof shall not continue beyond twenty-one years following the death of the survivor of the Settlor, and all those descendants of the Settlor who are living at the time of the Settlor's death. Upon the expiration of such period, this Agreement and any portions thereof shall immediately terminate, and the Trustee shall divide the balance of each such trust distributing one equal share to each living person then eligible to receive the income therefrom, and distributing, in the manner provided for in Paragraph 16(b) of this Agreement, one equal share among the descendants of each deceased person who, if living, would be eligible to receive the income therefrom.

11. Powers of the Trustee. The Trustee serving under this Agreement shall have the following powers with respect to each trust held under this Agreement, which may be exercised without prior authority from any court and without the consent of any beneficiary:

(a) To sell, transfer or exchange any real or personal property at such price and upon such terms, including credit, as the Trustee considers advisable.

(b) To invest and reinvest in such stock, common trust funds, mutual funds, money market deposit accounts, bonds, debentures, notes, securities, options or other real or personal property as the Trustee considers advisable, whether or not such investments are specifically authorized for fiduciary investment by statute or court decision.

(c) To enter into and perform any agreement with respect to the continuation, sale, merger, reorganization, recapitalization, dissolution or consolidation of any property or business interest.

(d) To cause any property to be issued to, held by, or registered in the name of the Trustee or in the name of the Trustee's nominee.

(e) To maintain agency or brokerage accounts and to employ attorneys, accountants and investment counsel, to rely upon their advice and to pay reasonable compensation for their services from income or principal or both as the Trustee considers advisable.

(f) To compromise, contest or abandon any claims by or against the trust and to settle with the proper officials by compromise or otherwise upon the amount of any tax due.

(g) To borrow, assume indebtedness, and to mortgage or encumber any asset of the trust; provided, however, that the Trustee shall not be personally liable for any such indebtedness which shall be payable only out of the property of the trust.

(h) To lend and to extend for any period the time for repayment of any amount owing the trust or owing the Settlor at his death, even if such period extends beyond the term of the trust.

(i) To exercise all voting, option, subscription and liquidation rights, and all other rights and privileges incident to any property in the trust.

(j) To invest two or more trust portions or shares in a consolidated fund in which each portion or share shall have an undivided interest.

(k) To make reasonable and equitable determinations of what is principal or income and what items shall be charged or credited to these accounts, even though particular determinations may be inconsistent with otherwise applicable state law.

(l) To make any payment or distribution due a minor to such minor's natural or legal guardian or custodian appointed under a Gifts to Minors Act, and the receipt of such payment or distribution by such guardian or custodian shall be a full and complete discharge of the Trustee who shall not be responsible for the application of such distribution.

(m) To make any divisions, payments or distributions of principal or income in kind or in cash, or partly in kind and partly in cash, and to do so without regard to the Income Tax basis of specific property allocated to any beneficiary and without making pro rata distribution of specific assets.

(n) Subject to any restrictions now existing or hereafter promulgated pursuant to Code Section 2702(a)(3)(A)(ii) and the Regulations thereunder, to establish such reserves as the Trustee considers advisable to pay any tax imposed by Chapter 13 of the Internal Revenue Code. In establishing such reserves, the Trustee may withhold amounts upon each taxable termination until the tax liability with respect to such termination is resolved.

(o) To make any elections and exercise any options allowed by the Code without making any compensating adjustments between income and principal or among any beneficiaries or their shares as a result of any such election or exercise.

(p) To manage, insure, sell at public or private sale, wholly or partly for cash or on credit, contract to sell, grant or exercise options to buy, convey, transfer, exchange, or lease (for a term within or extending beyond the term of the trust) any real or personal property of the trust, and to partition, dedicate, grant easements in or over, subdivide, improve, and remodel, repair or raze improvements on any real property of the trust, and in general to deal otherwise with the trust property in such manner, for such prices, and on such terms and conditions as any individual might do as outright owner of the property.

(q) To make allocations, divisions, and distributions of trust property in cash or in kind, or partly in each; to allocate different kinds or disproportionate shares of property or undivided interests in property among the beneficiaries or separate trusts, without liability for, or obligation to make compensating adjustments by reason of, disproportionate allocations of unrealized gain for federal income tax purposes; and to determine the value of any property so allocated, divided, or distributed.

(r) To pay all expenses incurred in the administration of the trust, including reasonable compensation to any Trustee, and to employ or appoint and pay reasonable compensation to accountants, depositaries, investment counsel, attorneys, attorneys-in-fact, and agents (with or without discretionary powers).

(s) To deal with the fiduciary or fiduciaries of any other trust or estate, even though the Trustee is also the fiduciary or one of the fiduciaries of the other trust or estate.

(t) To perform all other acts necessary for the proper management, investment, and distribution of the trust property.

(u) To use and expend any trust income and principal to (i) conduct environmental assessments, audits, and site monitoring to determine compliance with any environmental law or regulation thereunder; (ii) take all appropriate remedial action to contain, clean up or remove any environmental hazard including a spill, release, discharge or contamination, either on its own accord or in response to an actual or threatened violation of any environmental law or regulation thereunder; (iii) institute legal proceedings concerning environmental hazards or contest or settle legal proceedings brought by any local, state, or federal agency concerned with environmental compliance, or by a private litigant; (iv) comply with any local, state or federal agency order or court order directing an assessment, abatement or cleanup of any environmental hazards; and (v) employ agents, consultants and legal counsel to assist or perform the above undertakings or actions. Any expenses incurred by the Trustee under this paragraph may be charged against income or principal as the Trustee shall determine. No Trustee shall be liable for any loss or depreciation in value sustained as the result of retention of any property upon which there is later discovered to be hazardous materials or substances requiring remedial action pursuant to any federal, state or local environmental law, unless the Trustee contributed to the loss or depreciation in value, through default, willful misconduct or gross negligence.

12. Additional Powers Under Law.

(a) The powers granted in this Paragraph shall be in addition to those granted elsewhere in this Agreement and by law and may be exercised even after termination of all trusts hereunder until actual distribution of all property of this Trust, but not beyond the period permitted by any applicable rule of law relating to perpetuities. Notwithstanding any other provision or otherwise dispose of any interests in residential property forming a part of the property of this Trust only with the Settlor's written consent unless the Trustee believes that the Settlor is unable to manage his business affairs properly because of advanced age, illness, or other cause, in which event the Settlor's consent shall not be required.

(b) To the extent that such requirements can legally be waived, no Trustee hereunder shall ever be required to give bond or security as Trustee, or to qualify before, be appointed by, or account to any court, or to obtain the order or approval of any court with respect to the exercise of any power or discretion granted in this instrument.

(c) The Trustee's exercise or non-exercise of powers and discretion in good faith shall be conclusive on all persons. No person paying money or delivering property to any Trustee hereunder shall be required or privileged to see to its application. The certificate of the Trustee that the Trustee is acting in compliance with this Agreement shall fully protect all persons dealing with a Trustee.

13. Merger of Corporate Trustee. If any corporate Trustee designated to act or at any time acting hereunder is merged with or transfers substantially all of its assets to another corporation, or is in any other manner reorganized or reincorporated, the resulting or transferee corporation shall become Trustee in place of its corporate predecessor.

14. Duty to Account. Upon any Trustee's death, resignation or removal and otherwise at least annually, the Trustee shall render to the Settlor if he is then living, otherwise to each person who is then eligible to receive trust income, or to such person's legal representative, an account showing all receipts, disbursements and distributions of income and principal since the last such account. Unless objected to in writing within sixty days of its rendition, such an account shall be considered approved as rendered. Except for fraud or manifest error, the approval of an account by a beneficiary or his legal representative shall be final and binding upon all interested persons as to all matters and transactions stated or shown therein. At all times the Trustee shall be entitled to obtain a judicial settlement of any account.

15. The Trustee. [Name of Trustee] shall serve as Trustee of all trusts or portions thereof created under this Agreement until the earlier of his death or the completion of the Income Term.

(a) Removal of Trustee. Any Trustee may be removed by a majority of the persons then eligible to receive trust income. Removal of a Trustee shall be accomplished by providing to such Trustee a written notice of removal and a written acceptance of trust signed by a duly appointed successor Trustee. Upon receipt of such notice of removal and acceptance of trust, the Trustee being removed shall immediately deliver all the trust property to a successor Trustee who was appointed in the manner provided for in this Agreement and who has signed an acceptance of trust.

(b) Resignation of Trustee. Any Trustee may resign by giving sixty days written notice of such resignation to each person then eligible to receive trust income. A Trustee's resignation shall become effective only upon subsequent delivery of all of the trust property to a successor Trustee who was appointed in the manner provided for in this Agreement and who has signed an acceptance of trust.

(c) Successor Trustee. If [Name of Trustee] is unable or unwilling to act or to continue to act as Trustee, in the event of such Trustee's removal, and in any event upon the expiration of the Income Term if he is then serving as Trustee, [Name of Successor Trustee] shall serve as successor Trustee. If [Name of Successor Trustee] or any successor Trustee is unable or unwilling to act or to continue to act as Trustee or in the event of such Trustee's removal, a successor Trustee shall be appointed by a majority of the persons then eligible to receive trust income; provided, however, that any such successor Trustee shall be:

(i) A banking institution which has trust powers and which is organized under the laws of the United States or any one or more of the United States;

(ii) An attorney licensed to practice in the State of [state]; or

(iii) A certified public accountant licensed to practice in the State of [state].

Any successor Trustee shall have all of the title, powers, and discretion granted to the original Trustee, without court order or act of transfer.

(d) Any Change of Trustee. Any successor Trustee shall

(i) Provide a written acceptance of trust to the person or persons responsible for the appointment of such successor Trustee,

(ii) Provide a written receipt for all property delivered by the prior Trustee,

(iii) Have no liability for the acts or omissions of any prior Trustee, and

(iv) Be responsible only for those trust assets which are actually delivered by the prior Trustee.

If at any time during the term of the trust an income beneficiary is under a legal disability, such beneficiary's natural guardian or legal representative may exercise on behalf of such beneficiary the right of such beneficiary to participate in the removal of a Trustee or in the appointment of a successor Trustee.

(e) Completion of Distribution. A Trustee's rights, powers, duties and obligations shall continue until complete distribution of all trust property in the manner provided for in this Agreement or until complete delivery of all trust property to a successor Trustee.

16. Definitions and General Provisions. The following definitions and general provisions shall apply for all purposes under this Agreement:

(a) Survival. Any beneficiary of the trust who dies within thirty days after the Settlor's death, shall be considered not to have survived the Settlor.

(b) Descendants. "Descendants" of any person shall include all generations of the then living issue of such person. In making a distribution among the descendants of any person, the property to be distributed shall be divided into as many shares as such person has then living children and deceased children represented by then living descendants. Each living child shall take one share and the share of each deceased child shall be distributed among his then living descendants in the manner outlined in this Paragraph 16(b) for a distribution among the descendants of any person. For purposes of distribution, any child born after the death of his parent shall be considered as living at the death of his parent.

(c) Adopted Persons. The words descendant, child, issue and all other terms importing a lineal family relationship shall be considered to include legally adopted persons as well as blood relatives.

(d) Trustee Compensation. The Trustee shall be entitled to reasonable compensation for services rendered and responsibility undertaken.

(e) Captions. The captions at the beginning of provisions of this Agreement are for convenience of reference only and shall not define or limit such provisions in any manner.

(f) Context. When the context of this Agreement requires, words importing gender shall be construed to include either gender, whichever is most appropriate. Words importing the singular shall be construed to include the plural and the plural the singular. All references to "Trustee" shall include any successor Trustee who is then serving. All references to the "Internal Revenue Code" or "Code" shall refer to the Internal Revenue Code of 1986 as it may be amended from time to time.

(g) Governing Law. This Agreement shall be governed and construed in all respects in accordance with the law of the State of [state].

(h) Effective Date. This Trust Agreement shall become effective on the date when it is signed by the Settlor and may be so identified.

The Settlor hereby signs this Agreement this [date].

Witnesses:

[name]

[Name of Settlor]

[name]

Signature: [signature]

The Trustee signs this Agreement this [date].

Witnesses:

[name]

[Name of Trustee]

[name]

Signature: [signature]

STATE OF -------)

) ss: [date]

COUNTY OF ------)

On this [date], personally appeared, before me, [name], Signer of the foregoing instrument, and acknowledged the same to be his free act and deed.

[signature]

[Name of Notary Public]

My commission expires: [date]

STATE OF -------)

) ss: [date]

COUNTY OF ------)

On this [date], personally appeared, before me, [name], Signer of the foregoing instrument as "Trustee," and acknowledged the same to be his free act and deed.

[signature]

[Name of Notary Public]

My commission expires: [date]

Exhibit A

Legal Description of Property