IN THE CHANCERY COURT OF MADISON COUNTY, MISSISSIPPI

IN THE MATTER OF THE:

CAUSE NO.

CERTIFICATE OF FIDUCIARY

I, fiduciary in this cause, have hereby read, understand and agree to the following:

1. I understand that I, as fiduciary, am required to protect and preserve the funds owned by the Ward/Estate/Decedent, who is the person over whom I have charge.

2. I will not use any funds or make expenditures of the Ward's/Estate's/Decedent's funds without prior Court approval.

3. I understand that the Court can and will find me in contempt if it is proven that I have violated any of this Court's order(s) and that appropriate sanctions will be levied by the Court for any violations.

4. I agree and understand that I must consult with my attorney on any questionable expenditure prior to making said expenditure in order to gain appropriate legal advice and court approval regarding those transactions.

5. I understand that unless waived by the Court in advance, I will be required to submit formal, annual accountings to the Court reflecting my expenditures of the Ward's/Estate's/Decedent's funds.

6. My current address and phone numbers are as follows, and I understand that in the event this information changes, I must provide that information to the Clerk of this Court in writing.

NAME:___________________________________________________________

ADDRESS:________________________________________________________

CITY, STATE, ZIP:_________________________________________________

PHONE NO.:______________________________________________________

EMAIL ADDRESS:_________________________________________________

7. I have discussed with my attorney the duties and responsibilities required of my office as fiduciary and as set forth in this document, and I hereby agree to be bound by them.

Respectfully Submitted,

__________________________________

FIDUCIARY

SWORN ACKNOWLEDGMENT

STATE OF MS

COUNTY OF MADISON

This day personally appeared before me, the undersigned authority at law in and for the jurisdiction aforesaid, the within named , who having been by me first duly sworn, states on oath that the matters and facts set forth in the above Certificate of Fiduciary are true and correct as therein stated.

FIDUCIARY

SWORN TO AND SUBSCRIBED BEFORE ME, this the day of , 2012.

NOTARY PUBLIC

MY COMMISSION EXPIRES: