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Sample of an Estate Plan for a married couple

Sample of an Estate Plan for a married couple

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  • 1. Smith Family– DYNAMIC TRUST PORTFOLIO – File# 179652 – Electronic Signatures Verification Status – ALL APPLICABLE DOCUMENTS NOT "ESIGNED" (See Electronic Signature Page) ~ Provided By ~ MY LIFECARD PLAN 7373 E. Doubletree Ranch Rd., #200 Scottsdale, AZ 85258 www.MYLIFECARDPLAN.com
  • 2. GENERAL INSTRUCTIONS / IMPLEMENTATION Congratulations on your purchase! You have taken the first steps to help (i) enable specific proxy management/distribution of your assets in your stead (estate planning), and (ii) ensure your medical (emergency) preparedness. Now you will need to properly implement your plan. Enclosed are the documents that comprise your – Dynamic Trust Portfolio PLEASE NOTICE: A SHADED CHECKED BOX is positioned at the lower right hand corner of the pages where (a) you have to sign, (b) the Notary Public has to sign, (c) where witnesses enter their names and sign, and (d) where the current date is to be entered for the initial implementation of your Trust/Portfolio. NON-SHADED CHECKED BOXES are located on certain Trust pages (12-14) with optional decrees. The "Portable Document Format" / PDF page numbers posted to the right (>) of the document page numbers (listed below) locate the "signature page(s)" of each document stored in your electronic (Dynamic Trust Portfolio) PDF file. (NOTE: The Agent Notices are not to be signed until the time they are to be used.)  Co-Grantor (Marital) Living Trust / Pages 1 & 32 > . . PDF/53  Certificate of Trust / Pages 1 & 5 > . . . . . . . . . . . . . . . . PDF/61  Contemporaneous Property Agreement / Page 1 > . . . PDF/63  Assignment of Personal Property / Page 1 > . . . . . . . . PDF/64  Durable Power of Attorney Assets / Pages 3-4 > . . . . . PDF/100-1&104-5  Durable Power of Attorney Health Care / Page 4 > . . PDF/111&115  Advanced Health Care Directives / Page 8 > . . . . . . . PDF/127&137  Durable HIPAA Statement(s) / Pages 1-2 > . . . . . . . . PDF/128-9&138-9  Pro-Life Living Will(s)* / Pages 1-2 > . . . . . . . . . . . . . PDF/140-1&142-3  Living Will Declaration(s) / Page 3 > . . . . . . . . . . . . . PDF/146&149  Last Will & Testament(s) / Pages 1-2 & 4-5 > . . . . . . PDF/154-5&159-60 *The "Pro-Life" Living Will states that the Declarant does not want to be denied hydration and/or tube feeding – under any circumstances. Be advised that such a signed declaration may be deemed to be in conflict with a regular Living Will Declaration and/or other entries you may make in your Advanced Directives. NOTICE: The instructional information contained in this (Co-grantor) Dynamic Trust Portfolio is for reference ONLY, and is not intended to replace legal, tax planning, or personal health care counsel. You should obtain independent counsel before acting on any directives or other information described herein.PDF/2
  • 3. – PORTFOLIO INDEX – Section Document PDF Page Portfolio Summary -- Portfolio Summary . . . . . . . . . . . . . . . . . . . . . . . . . 5 Trustee Memorandum -- Trustee Administrative Memorandum . . . . . . . . . 15 Revocable Living Trust -- Revocable Living Trust Declaration . . . . . . . . . . . 22 Certificate of Trust -- Certificate of Trust . . . . . . . . . . . . . . . . . . . . . . . . . 57 Schedules, Ledgers & Deeds -- Contemporaneous Property Agreement . . . . . . . 63 Assignment of Personal Property . . . . . . . . . . . . . 64 Property Schedules (A/B/C/D) . . . . . . . . . . . . . . . 65 Personal Property Schedules (Distribution) . . . . 70 Subtrust (A/B/C) Accounting Ledgers . . . . . . . . . 72 Locater Reference Ledger . . . . . . . . . . . . . . . . . . . 75 Administrative Documents -- Appointment of Nominee Trustee . . . . . . . . . . . . 78 Trust  “B”  Apportionment  Amendment . . . . . . . 79 Trust  “B”  Five  &  Five  Amendment . . . . . . . . . . . 80 Trust  “B”  Forfeiture  Amendment . . . . . . . . . . . . 81 Relinquishment of Trustee Duty to Spouse . . . . 82 Reinstatement as Co-Trustee . . . . . . . . . . . . . . . . 84 Relinquishment of Trusteeship / Successor . . . . 86 Successor Trustee Notice . . . . . . . . . . . . . . . . . . . 88 Successor Trustee Declination . . . . . . . . . . . . . . 89 Successor Trustee Termination . . . . . . . . . . . . . . 90 Amendment / Trustee Appointment . . . . . . . . . . 91 Amendment / Distribution of Trust Assets . . . . . 92 Surviving Spouse Disclaimers . . . . . . . . . . . . . . . 93 Physician Medical Certifications . . . . . . . . . . . . 95 Durable Powers of Attorney -- Durable Power of Attorney / Over Assets . . . . . 98 Durable Agent Notices / Assets . . . . . . . . . . . . . . 106 Durable Power of Attorney / Health Care . . . . . 108 Durable Agent Notices / Health Care . . . . . . . . . 116 Living Will & Directives -- Advanced Directives / HIPAA Statements . . . . . 120 Living Will Declaration . . . . . . . . . . . . . . . . . . . . 144 Last Will & Testament -- Last Will & Testament / Pour-over Wills . . . . . . 151 Trust Assets & Correspondence -- Guideline to Funding . . . . . . . . . . . . . . . . . . . . . . 162 Joint Request / Asset Retitlement . . . . . . . . . . . . 168 Sole Requests / Asset Retitlement . . . . . . . . . . . . 169 Sole Requests / New Beneficiary Change . . . . . . 171 Sole Requests / Cont. Beneficiary Change . . . . . 173 Joint Irrevocable Stock & Bond Powers . . . . . . 175 Sole Irrevocable Stock/Bond Powers . . . . . . . . . 177PDF/3
  • 4. PORTFOLIO SUMMARY Introduction Congratulations on making the decision and taking the time needed to set up your Revocable Living Trust Estate Planning Portfolio. This Living Trust Portfolio represents a detailed and well organized estate plan for you that will meet your personal estate planning goals and objectives when implemented and funded properly. This first section, containing the Portfolio Summary, has been designed as a guide to take you through the rest of your Estate Planning Portfolio. Here you will find concise explanations of each subsequent section. The Portfolio Summary can be used as a reference for explanations of all of the various legal documents used in creating your estate plan. It also contains brief, generic summaries of each article in your trust document itself. In this section, you will find information about various documents and functions of your Portfolio. If you have a (Portfolio) question you cannot find an answer to, then you should contact your legal counsel or tax advisor. This section will also be helpful to your successor trustee concerning the use of certain administrative and other documents. If, at the time your successor trustee begins serving as trustee, you are unable to explain to hxm/hxr the basic functions of your estate plan, this section can be used as an additional reference for your successor trustee - with the Trustee Memorandum (proceeding). This section is for instructional purposes only. There are no legal documents contained in this section and no documents to sign. _______________PDF/4
  • 5. PORTFOLIO SUMMARY (Marital Universal [A/B/C] Trust) First, thank you for your purchase. We know that you will be well served with this comprehensive estate plan. With the Revocable Living Trust (RLT), you have incorporated what is now a very popular mechanism used by millions of Americans that will protect you from unnecessary expenses incurred through formal administration of your estate (during lifetime and) when transferring your assets upon decease and allow you to maintain complete control of your estate. These objectives will be easily accomplished provided that your assets are transferred into the trust. In all likelihood, it would be of vital importance that your assets be transferred into your trust as soon as possible. The Trustee Memorandum (next section) covers that subject as well as the last page of this section. The Living Trust is actually only one of several parts of your entire Estate Planning Portfolio which includes various documents that will be very convenient to you and your family when certain needs arise requiring their use. Each document, and how they are used, will be discussed in this summary. The Portfolio Summary was designed to help give you a better understanding of your Portfolio. You can study this summary along with the documents in your Portfolio at your leisure. As you can see, there are ten (10) sections in your Estate Planning Portfolio including this one that you are now in. Let us briefly discuss each section: PORTFOLIO SUMMARY This first section (the one you are now reading) contains an explanatory of your Portfolio. It is designed to help you familiarize yourself with your entire compilation of estate planning documents. This explanatory/summary will be a guide for you now and then later when your successor trustee assumes the administration of the trust. TRUSTEE MEMORANDUM This second section is a directive for trustee duties and functions which are to be performed at different phases of trust administration. It is not intended to take the place of professional advice and help if it is needed; however, it can be used as a general guideline regarding the responsibilities of the trustee of your trust. Portfolio Summary Page 1 (of 9)PDF/5
  • 6. REVOCABLE LIVING TRUST This third section is the actual trust itself. Your Revocable Living Trust (RLT) is, as the name implies, fully revocable. This means that you may alter, amend or totally revoke the trust, in part or in whole, without the approval of any other person concerning your own property (your spouse has control of his/her property). The following is a brief review of each Article in your trust: The Declaration and Recitals declare (i) who you are, (ii) what you are and (iii) your purpose for establishing a revocable living trust. The name you have given your trust is shown here as well. Occasionally, transfer agents want to know the name of your trust for transfer/retitling purposes although (legally) it is not necessary to use the name of the trust as a title owner. Only the name of the trustee and the date the trustee was proclaimed as trustee (UDT) are necessary for retitling purposes (although the name of the trust can be used also). Article One - defines how your property is held in the trust, i.e. - community, tenants-in-common or sole & separate property. Instructions are given as to the use of the Chattel Schedule for the disposition of your personal property to specified persons. This allows you to hold your personal property in trust and have it distributed by the trustee at time of death, rather than by your Will, and thereby eliminating the need to have it probated. Article Two - states your reservation of rights, as settlors, and declares your power and authority to change or revoke a portion or all of the trust. These revocation rights are also referred to as "general powers of appointment". Article Three - is a statement concerning basic trustee responsibilities of the successor trustee, if appointed during the (mutual) lifetime of the settlors, as it regards the administration of the settlors assets for the settlors benefit. When you (as settlors) are serving as trustee, trustee administration is more of a token formality, rather than an actual function, during your joint lifetimes. Article Four - is used as a directive for the payment of any debts of the first spouse to die. Additionally, this Article provides the language used to determine what type of Marital Trust format will ultimately be utilized for your estate plan. There are three different Marital Trust formats normally used in Marital Trust planning - Non A/B Trust, the A/B Credit Shelter Trust and the A/B Trust with a QTIP provision. Notwithstanding the provisions of this Article to split the Trust into 3 distinct sub-trusts (A/B/C) at the death of the first spouse to die, in the event that the aggregate estate value (of both spouses) is less than the federal exemption equivalent amount at the time of death of the first spouse to die, then the trustee is not to partition the trust assets (into A/B) because the trust provides that all of the trust estate shall be under the control of the surviving spouse in the event that the aggregate estate value is less than the exemption amount at the time of the first spouses death. Portfolio Summary Page 2 (of 9)PDF/6
  • 7. The Non A/B format does not utilize any tax planning formulas - when the first spouse dies the entire estate belongs to the surviving spouse. The A/B format uses a Credit Shelter (Bypass Trust) to take advantage of the unified credit of the first spouse to die and yet keep the estate of the first spouse to die IN TRUST for his/her lifetime use. The A/B/C format contains the A/B provisions along with a Qualified Terminable Interest Property (QTIP) provision; the QTIP provision allows the decedent settlor to control his/her entire estate even if it exceeds the federal exemption equivalent amount and still shelter it, or at least defer it, from transfer tax. Whatever size your estate is at the death of the first spouse to die will determine which tax planning format is to be used in this Marital Universal Trust. Concerning the accounting procedure(s) to be used when creating A/B partitioning at the first spouses death, in many cases, the trustee need not partition undivided interests or "retitle" certain properties for this accounting function; allocations can oftentimes be used instead. Whatever method is used, it is important that the allocations or divisions be made and be properly accounted for when creating an A/B split. If no A/B split is needed then such accounting entries do not have to be made. In many cases, the trustee need not make a division of undivided interests or "retitle" certain properties for partitioning the trust assets (when necessary); rather the allocations can be accomplished by using prorata values and accounting procedures. Article Five - concerns the administration of the Survivors Trust "A" after the A/B split. The surviving spouse has full control (general power of appointment) of Trust "A". The surviving spouse may elect to have the successor trustee serve at this time and this Article shows how the successor trustee is to administrate the trust estate on behalf of the surviving spouse. Additionally, the successor trustee may elect to pay any debts of the surviving spouse, after such spouses death, out of the funds of Trust "A" before such funds are commingled with Trust "B" (and Trust "C"). Article Six - outlines those administrative provisions you have elected to use concerning assets of Trust "B" (Decedents Trust) and Trust "C" (Qualified Terminal Interest Trust) used to support the surviving spouse (or children from Trust "B", if so elected) during surviving spouses lifetime. Trust "C", as defined in this Article, must pay all income to the surviving spouse for his/her lifetime. Also, any distributions that are to occur immediately at the death of the first spouse to die will be described in this Article. Article Seven - makes provisions for the trustee to allocate legal and binding reductions of a trust estate, as a result of estate taxes, passing to the beneficiaries of the settlors estate who are beneficiaries of property passing outside of the trust. Without these provisions, there could be unequal reductions in estate portions allocated to the trust beneficiaries in the event that there is an estate tax due. An example - beneficiaries of your life insurance, who may be different than the beneficiaries of your trust, would receive the insurance proceeds in full without a prorata reduction relative to any estate taxes due. Article Eight - outlines the final distribution and administration of the residual trust estate which is the remaining property in trust after the death of the last spouse to die. The instruction concerning the portions of your estate to be distributed to your beneficiaries or held in trust for a particular time are given in this Article (and Article Nine when necessary). Portfolio Summary Page 3 (of 9)PDF/7
  • 8. Article Nine - lists not only the person(s) (usually yourselves) presently appointed to serve as trustee but also lists the names of the successor trustee(s) and describes the selection process of such appointees. The successor trustee(s) appointment is made effective upon certain contingencies which are: (a) resignation, (b) incapacitation or (c) death of the settlor(s). All appointments are, of course, subject to your change. Article Ten - concerns trustee administrative guidelines regarding property held in trust for beneficiaries who are not to receive an outright distribution. This Article is also a full definition of the parameters of the trustees power and authority. These rules are generally referred to as "prudent man" rules. These rules coincide with the Uniform Trustee Powers Act formulated under a uniform code which was adopted by most states. Unless you have directed otherwise, the successor trustee shall govern the trust assets (if the assets are to be held in trust after the death of both settlors) as would a prudent man seeking to gain income, interest and dividends yet preserving the principal; additionally, the trustee may invest in equities as well as debt securities. Article Eleven - applies to legal descriptions, general governing provisions and definitions of trust law. These standards are recognized in general trust law and usually need not be changed unless you wish otherwise - example - you may not want reference to adopted children as legal descendants for the purposes of receiving an inheritance. Article Twelve - outlines the basic procedures for the trustees receiving insurance proceeds payable to him/her as a trustee/fiduciary. This Article will help expedite the payment of any insurance policy to be payable to the trustee (as a result of making the trust the beneficiary) as the insurance company is careful to not make any mistakes concerning payments to beneficiaries of their insurance policies. Article Thirteen - pertains to any stock which may be transferred into the trust that is classified as Professional Corporation (PC) stock. PC stock can only be administrated by the professional, thus as sole trustee of, and not by any other person who is considered to be a "non-professional" as described by state statues. Article Fourteen - acknowledges the non-liability of separate parties such as transfer agents and the like who, absent from fraud, shall not be liable for any impropriety committed by any trustee of your trust. Article Fifteen - allows the Certificate of Trust to be used in lieu of the trust itself when presenting evidence of (i) the settlors duly appointed general power of appointment and (ii) the trustees authority concerning conveyances and transfer of assets from and/or to the trustees. Article Sixteen - gives power to the trustee to transmute (or change) jointly owned property, of the spouses, to sole and separate property of each spouse. This is applicable in cases where such transaction may avoid a "spend-down" of the trust estate when one spouse (during settlors joint lifetimes) requires some type of professional or institutionalized care in which a local, state or federal agency would otherwise supply the care or funds for such care. Portfolio Summary Page 4 (of 9)PDF/8
  • 9. CERTIFICATE OF TRUST This fourth section contains the Certificate of Trust which is a document containing certain provisions from particular Articles of the trust itself. So, we can refer to this instrument as an "abstract" of the trust. This abstract is complete with enough information taken from your trust to enable those who are transfer agents (brokers, bankers, account managers etc.) to legally, and without any liability on their part, transfer your property from you - to you as trustee - without (the agents) having to secure a complete copy of the trust. Remember that once the certificate is executed by your signature(s), you can continue to use a photo copy(s) of the executed certificate as an original. SCHEDULES, LEDGERS & DEEDS This fifth section contains transfer/funding related documents such as the Contemporaneous Property Agreement, Assignment of Tangible Personal Property, Quit Claim Deed(s), Secured Realty Interest, etc. The Asset Schedules onto which you may list your titled assets (death benefits payable to trustee are listed on Schedule "D") that are funded into your trust are held in this section. You will retain the character of your property, whether it is jointly owned or separately owned, by the proper entry on these respective Schedules. The Asset Accounting Ledgers are to be used by the trustee (usually the surviving spouse) to designate assets as portioned or held on account to each respective subtrust (A, B & C) for record keeping. Also included in this Section is the Locater Reference Ledger for use in maintaining a handy list of pertinent names and addresses of beneficiaries of your Trust. ADMINISTRATIVE DOCUMENTS This sixth section is a compilation of documents reducing or eliminating any need for future drafting of such documents thereby voiding any additional costs; they have already been created for you. Lets briefly discuss each one: Amendment - Apportion Trust Estate allows you, the settlors, to determine, before the death of the first spouse to die, that the marital trust will be split/apportioned into two separate trusts - Trust "A" & Trust "B" - regardless that it may not be necessary for tax purposes. The premise of this amendment technique allows the estate of the first spouse to die to be protected from a spend-down of his/her portion of the estate because of a lawsuit or because of a long-term nursing care situation that may cause a spend-down of the surviving spouses estate. Also, it ensures that the decedent spouse can control his/her portion of the estate even after death in that it will be administrated and distributed according to his/her bequest only. Amendment - Five & Five Rule allows you, the settlors, to select, before the death of the first spouse to die, the option of allowing the surviving spouse to receive Five Thousand dollars ($5,000) or five percent (5%) of the principal of the Trust "B" (if the A/B format is used), whichever is greater, on an annual non-accumulative basis; this does not forego any of the other options already in place. Portfolio Summary Page 5 (of 9)PDF/9
  • 10. Amendment - Surviving Spouse Forfeiture of Trust "B" Benefits by Remarriage can be executed by both settlors to require that if the surviving spouse remarries then the surviving spouse shall no longer receive benefits of Trust "B" and it shall terminate and be distributed outright to the heirs as though the surviving spouse had then died. Relinquishment of Trustee Duty (for each spouse) allows a settlor to voluntary resign as trustee thereby allowing the remaining settlor to serve alone. This is a voluntary relinquishment of a co-trusteeship position with a spouse. Reinstatement as Co-Trustee (for each spouse) allows a settlor who has voluntarily resigned to reinstate (i.e. - reappoint) himself/herself. Relinquishment of Trusteeship (to successor trustee) is the document that you, as settlor, would execute in the event you wanted to voluntarily relinquish your trusteeship to the successor trustee whom you have already named and appointed in the trust. This document can be executed by both spouses simultaneously or the surviving spouse. Successor Trustees Notice is the document that will be executed by the named successor trustee upon one of three of the contingencies occurring that would empower him/her with the right and authority to act as trustee. This Notice is to be used for fiduciary transactions as a trustee. It enables the parties, whom the successor trustee is transacting with, to know that such appointee is now acting as trustee. This document would be used with one of any three documents viz - (i) Relinquishment of Trusteeship, (ii) Medical Certification or (iii) Death Certificate. Successor Trustees Declination is the document used by the appointed successor trustee if he/she desires to rescind his/her appointment by vacating or declining such appointment. The execution of this document would be sufficient proof of his/her vacation/declination. The trustee resignation can take up to 60 days, after the deliverance of the Notice, to become effective. Once trusteeship is accepted, however, it generally requires the majority vote of the beneficiaries to allow the trustee to resign from such duties in order for the resigning trustee to be indemnified from and against any liabilities. Successor Trustees Termination is the document you would execute in the event you decide to revoke the trusteeship of the (successor) trustee who may be serving at the present time (other than yourselves) because of your earlier incapacitation or resignation. This makes it clear to all transfer agents that you, the settlor(s), are now serving as trustee of your own trust. Amendment - Trustee Appointment Change is the document you would execute in the event that you change your mind about your appointment of the successor trustee whom you had appointed to serve in such capacity. Do not confuse this with the Successor Trustees Termination document; that document applies to after the successor trustee has begun serving as trustee. This document applies to making the change before the successor begins serving. Identify the name of the rescinded appointee under the paragraph of revocation and then list the name of the person you are appointing to serve in lieu of the first appointee. Portfolio Summary Page 6 (of 9)PDF/10
  • 11. Amendment - Distribution of Assets allows you to make a (small) change in your trust describing the final distribution of your assets. Normally, you should seek professional help with this type of change in your trust. Nevertheless, a small change or alteration can be accomplished with this document and therefore you need not incur additional costs to draft an amendment for such a change/alteration. Medical Certification(s) is the document which would be executed by your attending physician on your behalf to certify that, in his/her opinion, you are unable, because of mental or physical incapacities, to carry on the normal duties of trustee of your own trust. This document legally circumvents any requirements that you ever have to be adjudicated in a court of law as being incapacitated (providing your assets are held in this trust) and thus a court- governed conservatorship will be unnecessary. DURABLE POWERS OF ATTORNEY This seventh Section contains separate documents used for two different purposes viz: to (i) give another person the power to make fiduciary decisions, on your behalf, concerning any assets not funded into your trust at the time of incapacitation and to (ii) make medical decisions on your behalf in the event you are unable to do so: Durable Power of Attorney Over Assets gives attorney-in-fact powers over your assets to the person you have named as agent therein. It is called a "springing power of attorney" in that it springs into effect when the contingency of incapacitation occurs (although you can elect to make it effective immediately). This enables the DPA agent, whom you have selected, to fund assets that have not been funded into the trust (for one reason or another) instead of the necessity of a court-ordered conservatorship over such assets in the event of your incapacitation. Durable Agent Notice is to be executed by your appointed agent, but only at the time he/she is to begin acting on your behalf as your agent. The notice serves to notify, in writing - whom it concerns - that your agent has accepted the appointment and will carry out such duties. Durable Power of Attorney for Health Care (DPAHC) will allow your agent to make medical decisions on your behalf in lieu of your own decisions concerning your desire for specific medical procedures such as surgery or other medical treatment (including the termination of life support systems), in the event you were unable to do so. It is now so closely used in conjunction with the Living Will Declaration (below) by a large number of medical institutions that the two documents are considered as one complete document in that one cannot legally function without the other. Portfolio Summary Page 7 (of 9)PDF/11
  • 12. LIVING WILL & ADVANCE DIRECTIVES This eighth Section contains the Living Will and Advance Health Care Directives which allow you to determine how you want medical care administered if you have a terminal illness or are in a comatose state and all natural hope of your recovery has been exhausted. If such a condition should happen to you, these instruments will serve to give notice that you desire to not be kept alive by such artificial means. Your Living Will agents are also considered to be the guardian of your person. In most cases, your Advance Health Care Directive can take the place of a Living Will. LAST WILL & TESTAMENT This ninth Section contains your will; however, it is better described as a Pour-Over Will. It is always used in conjunction with a RLT and its function is to convey everything (you may have forgotten to fund) into the trust at the time of your death. Such assets will go through probate first, however, unless they are minimal in value. Additionally, you may appoint guardians for your minor or incapacitated dependents and give any last instructions or statements in your Pour-over Will. TRUST ASSETS & CORRESPONDENCE This tenth (and last) section contains "retitlement" letters (or other correspondence regarding the trust) which you can mail to respective agencies (transfer agents) for transfer of title or change of beneficiary of your various assets. There are other documents included in this section for other functions. Lets examine each document: Joint Request for Asset List & Retitlement is a requisition letter to send to transfer agents, account managers, bankers etc. (transfer agents) requesting (i) a list of your assets as well as (ii) a change of title of your jointly-held assets from yourselves to yourselves as trustee with assets held in that particular account; make as many copies of this letter as necessary for you to accomplish this matter. The letter is self explanatory to the agent and should assist you very nicely. Joint Request for Asset Retitlement functions the same as the previously mentioned requisition letter but without a request for a list of your assets held on account with the firm. The separate letter-requests (the documents following this one in the Portfolio) function the same way but are for requesting retitlement for accounts held in a single name (spouse or spouse) rather than for those held jointly. Requisition for New Beneficiary Appointment (spouse or spouse) is a requisition letter used to appoint the trust as the primary beneficiary of your life insurance or other payable-on-death assets. It would be wise, in most cases, to keep your spouse as the primary beneficiary of your IRAs and/or other qualified plans so that a tax free roll-over, of qualified assets, would be available for your spouse. If your estate is large enough and your life insurance policy is substantial (about $100,000 or more) then, in all likelihood, it would be advantageous to appoint the trust/trustee as the primary beneficiary of the insurance for the purposes of helping to avoid estate tax consequences at the death of the surviving spouse. Portfolio Summary Page 8 (of 9)PDF/12
  • 13. Requisition for Contingent Beneficiary Appointment (spouse or spouse) is a requisition used to appoint the trust (i.e. - the trustee) as the contingent beneficiary of your insurance policies etc. In the event the primary beneficiary does not survive you (and there was no contingent beneficiary alive) then the proceeds of your insurance, for example, would go to the probate estate of the primary beneficiary since such beneficiary would not be alive to receive the proceeds. Naming the trust as the contingent beneficiary will solve that problem. For marital estates that are average or smaller, its generally sufficient to name the trust as the contingent beneficiary. It is recommended, however, that you consult your advisor on these matters. Stock & Bond Powers (joint and/or separate) are designed for retitling stock or bond certificates without having to actually sign the certificate itself. This precludes mailing or delivering certificates than can cause inconveniences or losses. A Signature Guarantor (a member of the NYSE or commercial bank or trust company having its principal office or correspondent in New York City) must "guarantee" your signature. When the signed stock and/or bond powers are received by the transfer agent, they are simply attached to the certificate - validating the transfer. Portfolio Summary Page 9 (of 9)PDF/13
  • 14. TRUSTEE MEMORANDUM Introduction This second section, containing the Trustee Memorandum, has been designed as a directive for trustee duties and functions to be performed at different administrative phases of your trust. It is not intended to take the place of professional assistance/advice. However, it is a helpful guide regarding general responsibilities of the trustee. There are three different phases of trust administration over the entire existence of your trust viz - (1) administrative duties during the lifetime of both settlors, (2) administrative duties after the death of the first settlor to die, i.e., during the lifetime of the surviving settlor and (3) administrative duties after the death of the surviving settlor. There will be functions and duties for the trustee to perform that are unique to each phase. This section will help define the differences and identify the functions. Trust law exists around the ability of one (the settlor) to bestow responsibilities on another (the trustee) who then accepts the obligations and carries them out. The Trustee Memorandum will be helpful to any person carrying out these important trust administrative functions. This section is for instructional purposes only. There are no legal documents contained in this section and no documents to sign. This memorandum is not intended for replacement of tax or legal counsel; it is provided only as a guideline for administration of a living trust. _______________PDF/14
  • 15. TRUSTEE (ADMINISTRATIVE) MEMORANDUM (Marital Universal [A/B/C] Trust) There are three persons or entities in a Revocable Living Trust (RLT) - (i) settlor, (ii) trustee and (iii) beneficiary. This memorandum is a reference digest on the duties and functions of the trustee. There are three phases of trustee management/duties in a marital RLT defined as follows: PHASE ONE - SETTLORS JOINT LIFETIMES: - Transferring / Funding of Assets - A. Your RLT is in existence the moment it is executed by you, the settlors. In order to obtain the benefits of your trust, however, it is absolutely imperative to transfer (to fund) your assets to the trustee. That is what the name "living trust" implies - the trust is funded while the settlors are living. Different types of assets may require different procedures for funding; however, the final outcome must always be the same - to hold the assets as trustee. Remember that only those assets held in the trust (except for payable-on-death assets or right-of- survivorship property) will avoid formal and supervised administration - probate. B. In addition to the requisition for retitlement letters provided (in the last section of this Portfolio) for transferring assets to your trust, you should use the Certificate of Trust contained in Section Four; that is - have it available to present to the transfer agent if he/she needs it. By doing so, you are providing him/her with a document proving your power and authority to make such transfer which is a transfer from your present ownership status to your ownership status as settlors/trustees. 1. Assets you presently own which have a "certificate of title" certifying ownership (i.e. - real estate, bank accounts, stocks, bonds, mutual funds, limited partnerships, safe deposit boxes, etc.) should always have the title transferred or changed - from you to you as trustee (or to whomever is serving as trustee). Here is an example, which is used in this Portfolio, of how to title your assets -- HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: (date of trust) , 2012 a. Real estate held in your name must be funded into the trust with a quit claim deed that will transfer that certain piece of real estate property from you to the trustee - to your trust. Trustee Memorandum Page 1 (of 6)PDF/15
  • 16. b. All property that you are carrying paper on (example - deed of trust) is not transferred as such; however, you must transfer the interest of that paper (the payments sent to you) to the trust (to the trustee). After you have received the draft (a Secured Realty Interest document) conveying such interest, you would then send a copy of the deed of trust and the conveyance document in your Portfolio (the Secured Realty Interest document) to the payor of the deed of trust and a requisition saying that from henceforth he/she is to send the payments to the trustee. 2. Assets without a certificate-of-title should have an "assignment" document (or bill of sale) assigning such asset to the trust. The Assignment of Tangible Personal Property document will accomplish that for you. Assets held in bearer form (certificate-less securities) should be kept in a safe deposit box titled to the trustee. 3. Assets such as IRAs, other qualified plans, annuities and life insurance policies which have a payable-on-death provision in the contract (i.e. - a named beneficiary to receive the assets at death of the insured) should name the trustee as either the primary or contingent beneficiary and be listed on Schedule "D". Caution should be taken to ensure that when a surviving spouse has a 60 day period for a roll-over option, such as in some IRAs, then the trustee should be named as the contingent beneficiary. The spouse would, in this case, remain as primary beneficiary. - Administration & Duties - C. During your joint lifetimes, as the settlors, you have complete and unhindered control of the trust assets (even if another than yourselves is serving as trustee). In effect then, the trustee has no significant responsibility during the joint lifetimes of both settlors (unless - neither of the settlors is serving as trustee or are incapacitated). D. You, as settlors, will continue your own fiduciary duties basically the same as you did before you set up the trust with the exception that you buy and sell as trustees; thus, transactions concerning your assets are accomplished as trustees and not as individuals. E. The IRS no longer requires a separate tax ID number for a RLT (during the joint lifetime of the settlors) as long as (i) the settlors file jointly and (ii) either one (or both) of the settlors is serving as the trustee; simply report all income from trust assets on your 1040 just as before. If any transfer agent insists on a tax ID number for your joint trust, instruct him/her to read the retitlement letter carefully and to use your social security (personal tax ID) numbers. 1. If the above criteria are not met then the trust becomes a taxable entity and a federal tax ID number must then be obtained by the filing of a SS-4 application form. Thenceforth, all income must be reported on a 1041 (fiduciary income tax) form. 2. Check with the state revenue office of your domicile concerning the filing of any fiduciary tax return regarding your living trust. Most individual state requirements are similar to the federal government. Trustee Memorandum Page 2 (of 6)PDF/16
  • 17. PHASE TWO - AT DEATH OF FIRST SPOUSE TO DIE: - Taxation/Allocation/Record Keeping - F. The Marital Universal Trust has been designed to cover all tax phases of marital trust planning. If it is not necessary, for tax purposes, to apportion the trust estate into two separate trusts (Trust "A" & Trust "B") then the trustee is not required, by the provisions of this trust, to create the two trusts; the only exception would be if the settlors changed their minds (during their joint lifetimes) and executed an amendment to require the split regardless of the size of the estate. 1. If the aggregate value of the entire trust estate is less than the then available exemption amount (at the time of death of the first settlor to die), as it pertains to the transfer tax laws in effect at the time of this writing, then there is to be no split into Trust "A" and Trust "B". 2. If the aggregate value of the entire trust estate is equal to or greater than the then available federal exemption equivalent amount, then there shall be a split into Trust "A" and Trust "B". 3. If there is a need, for tax purposes, to create the split at the death of the first spouse to die then the trust estate should be allocated into three separate trusts - the Survivors Sub-Trust "A", the Decedents Sub-Trust "B" and the Qualified Terminable Interest Property Sub-Trust "C". Trust "C" would only be created, however, if the value of the estate of the first spouse to die exceeds the exemption equivalent (from the transfer tax credit) then available to the decedents estate. G. All trust assets should have a proper evaluation assigned to them. Additionally, the trustee must apply for a tax ID number, for Trust "B", by filing a SS-4 Form (not necessary if the surviving settlor does not want to subdivide the trust). All income, capital gains etc. must then be reported on a 1041 (fiduciary income return); all income beneficiaries must be sent a IRS K-1 form (and corresponding state forms) for the purpose of reporting income paid to them from Trust "B"; the surviving spouse must receive all income from Trust "C" and thus the same filing requirements apply. H. If it is necessary to create Trust "C" because of the excess value of the Decedents estate, the trustee will need to take the "marital deduction" for the Trust "C" property. QTIP is an acronym for "qualified terminable interest property", which, as the name implies, may qualify a portion of the Decedents estate for the marital deduction. Thus, there is no tax to be paid on the Decedents estate (until the Survivor dies, if necessary) even if it exceeds the available exemption equivalent provided that trustee properly elects to qualify the value of Trust "C" for the marital deduction. Current rules allow a fiduciary (trustee) to shelter the value of Trust "C" under the Survivors transfer credit (to the extent available) at the Survivors death. At the death of the Survivor, the QTIP property goes to the Decedents beneficiaries - determined in the trust by the Decedent (first spouse to die) before his/her death. Trustee Memorandum Page 3 (of 6)PDF/17
  • 18. 1. The burden of proof is on the trustee to prove the value of trust assets for any estate tax due. Generally, for valuation purposes, the trustee must adhere to the "highest and best use" rule when giving valuations to property for estate tax purposes. 2. A 706 Federal Estate Tax return can be filed even if the decedents estate is under the federal exemption limits and not subject to estate tax as a result of his/her available Unified Credit; this is especially true if the decedents gross estate value is near the maximum allowable Exemption Equivalent. This establishes, with the IRS, the value of the decedents property at date of death (or six months later). Copies of appraisals etc. should be submitted with a 706 if filed. The decedents executor is required to file when the gross estate is over the current allowable Exemption Equivalent. 3. Determinations of income, expenses and capital gains are usually divided and allocated to the respective trusts. Additionally, federal law enables the trustee to minimize or eliminate taxes by allowing a valuation of trust assets either at the date of death or at a date six months after death. 4. To facilitate better management of assets, it is allowable to use "prorata" allocations instead of re-registering title to assets or dividing undivided interests. Whichever method is used, it is important that book entries in the accounting records be made in regard to the allocation of such assets to the respective trusts. The trustee must distinguish between income and principal in receipts and disbursements. Fair allocations may be required between income and principal if there are income beneficiaries receiving income. - Trustee Powers & Duties - I. As a rule all trustee powers are set forth in the trust instrument. However, there are certain implied laws (Uniform Trustees Powers Act) which may be utilized in the general administration of the trust. It is important to know that one of the trustees duties concerning the Decedents Trust is that preservation of principal is a primary duty of the trustee; he/she must act in good faith toward the income beneficiaries and remaindermen. J. The trustee may delegate ministerial duties (accounting etc.) to another but may not delegate discretionary authority and decision making unless the trustee formally resigns (Successor Trustee Declination document). K. In your trust, the trustee can buy and sell between himself/herself and the trust (unless drafted otherwise). This does not, however, allow for any self dealing if there is the possibility of detriment to the beneficiaries. Generally, the trustee may not commingle his/her property with that of the trust. Thus, proper record keeping is important. L. The trustee has been given basic "prudent man" powers (unless you have determined otherwise) which allow him/her to invest in equities as well as debt securities. In general that means he/she is allowed to invest as a prudent man would in obtaining income and at the same time preserving the principal. Trustee Memorandum Page 4 (of 6)PDF/18
  • 19. M. If there are losses to the trust because of gross negligence or impropriety on the part of the trustee or if the trustee fails to pay a death tax that was due, he/she could incur personal liability. PHASE THREE - AT DEATH OF SURVIVING SPOUSE: N. Generally speaking, the duties of the successor trustee are basically the same as were those of the surviving settlor/trustee. At the death of the surviving settlor, the assets of Trust "B" and Trust "C" are added to by any remaining assets of Trust "A" if so designated (or as you may have determined otherwise in your trust) and shall be combined to create the Family Share which will either be divided into specific allocations or divided into trusts for further administration for minor children etc. O. The successor trustee may use the Certificate of Trust the same as the settlors did for the purpose of transferring and transacting assets from or to the trust; the reason is that - at this point, the trustee must now assume legal title to the assets. In making disbursements to beneficiaries, the trustee must file a Successor Trustee Notice (and accompanying appendages) with the respective transfer agents in order to initially obtain assets in his/her name - as trustee - so that he/she may assume his/her appointment of trustee. P. If the trust has been divided into different "sub-trusts" for the beneficiaries, the successor trustee will have to keep separate accounts and/or devise an accounting method of allocation to ensure proper allocation of income and/or principal distributions to the beneficiaries for assets held IN TRUST until the final distribution is made. Q. When a final distribution has been accomplished, the trustee has discharged himself/herself from the duties of the trustee, provided, of course, that proper accounting, tax return filing etc. has been made. R. The duties of an administrator of an estate (the personal representative) and the duties of a trustee of a trust (holding an estate in-trust) are usually quite similar if not identical in many cases. The following page will define some final actions that may be required by the trustee. Trustee Memorandum Page 5 (of 6)PDF/19
  • 20. - Administrator Checklist - THE FOLLOWING - is a guideline/checklist for the administrator (personal representative) of an estate. Generally the duties of an executor and trustee overlap. Usually the trustee is the same person as the executor. If they are not, then they must work together in accomplishing the goal of proper estate administration. Most of the following instructions are applicable in the administration of the estate at the death of the first spouse to die as well as for the successor trustee administration at the death of the surviving spouse:  The executor/trustee should immediately secure trust property for transferring such to himself/herself as trustee (the trustee will not be able to make transactions or distributions until title of such trust property has been properly vested to him/her). Funeral arrangements, or applicable proceedings, should be arranged if not previously made by the decedent and arrange for organ donations if the settlor or family expressed such a desire.  As soon as possible the executor/trustee should locate known assets, remove contents of decedents safe deposit box, apply for any Veterans Administration benefits, file life and medical insurance, cancel all subscriptions etc.; have property appraised; and apply for an estate ID number (Form SS-4) if the trust is currently or will be paying out income and, if necessary, file an estate tax return (Form 706) for the decedents estate.  The executor/trustee should now consider selling certain assets where necessary and invest proceeds in liquid income-producing accounts (if prudence requires); consider administration and final medical expense deductions on a 1041 or 706; check for accumulation of pension/profit sharing benefits and life insurance payable to the trust estate.  The executor/trustee should locate and list every insurance policy on the life of the decedent (regardless of who owns it - for the purpose of the 3-year inclusion rule) and check for any insurance policies on credit cards etc. Also, include a copy of any other trust of which the decedent may have been a grantor/settlor.  Where applicable, the executor/trustee may revaluate the estate by using the alternate valuation method and decide which date to use (date of death or 6 months later) on the 706 Form for final, property evaluation.  The decedents final 1040 is to be filed (if necessary) by the 15th of April of the year following the year of death; within nine months of death the 706 must be filed, if necessary; filing of any outstanding gift tax returns must be done; any tax due must be paid. NOTICE: Our office now offers easy-to-use, online ESTATE SETTLEMENT SERVICES; please contact our office for more information if estate settlement assistance is needed. Trustee Memorandum Page 6 (of 6)PDF/20
  • 21. ~ REVOCABLE LIVING TRUST ~ Introduction This third section contains the centerpiece of your Estate Planning Portfolio - the Revocable Living Trust. In particular, this is a Marital Universal (A/B/C) Trust - the trust format you have selected. This trust is completely under your control (see Article One). You can transfer your assets back out of your trust just as easily as you can transfer your assets in. Below are descriptions of Articles (of your Trust) that you should review first. Article Four defines the partitioning of the Trust that may be required for estate tax purposes. If your aggregate estate value is less than the federal exemption equivalent amount at the time of death of the first Settlor to die, then no partitioning would occur (unless otherwise determined by an Amendment). The stipulations to determine those events are found in this Article. Article Six outlines the administrative (and distributive) provisions of the estate of the first spouse to die - Trust B (the Credit Shelter Trust) and Trust C (the amount of the decedents estate, if any, which exceeds the exemption equivalent amount and qualifies for the marital deduction yet remaining under the control of the decedent spouse). Distributions of income and/or principal from Trust B and Trust C - to the surviving spouse are provided here. Also, if there are to be distributions to other beneficiaries, at the death of the first spouse to die, such distributions are described in this Article. Article Eight describes the final distribution of the Trust Estate at the death of the surviving spouse. Read this Article through carefully to be sure it conforms to the distribution format you want. Article Nine confirms your declaration that you are serving as trustee as stated. It also names the appointees that you have selected to serve as successor trustee(s). Article Nine mandates the contingencies that must occur before the successor trustee is to assume administrative responsibilities. Both spouses need to sign this document in the presence of a Notary Public. ________________PDF/21
  • 22. REVOCABLE LIVING TRUST Declaration & Agreement ~ RECITALS ~ This Revocable Declaration of Trust acknowledged and referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 is hereby made and entered into on this day being the date stated above between – HENRY J. SMITH & MARY A SMITH (a married couple) domiciled in the County of Maricopa, State of Arizona, hereinafter referred to as the "Settlors" and HENRY J. SMITH & MARY A SMITH domiciled in Maricopa County, State of Arizona, hereinafter referred to as the "Trustee". It is the primary purpose and intent of this Trust to provide for the management of the Settlors assets both presently and during any future period of disability. This Trust Agreement is a chosen alternative preferred to guardianship or formal conservatorship proceedings that are conducted in and supervised by a court of law. This Trust Agreement shall serve as a simplified means of accomplishing both lifetime and death transfers of both Settlors assets. ARTICLE ONE - Declaration of Property Ownership - 1.1. The Settlors have contemporaneously transferred certain property to the Trustee with the signing of this agreement, the receipt of which they, as Trustee, hereby acknowledge. 1.2. The Settlors shall list all of their co-owned property on Schedule "A" attached herewith to be held in this Trust as Community property. All property owned separately by HENRY J. SMITH, Spouse, held in this Trust as his Sole and Separate property shall be listed on Schedule "B" attached herewith. All property owned separately by MARY A SMITH, Spouse, held in this Trust as her Sole and Separate property shall be listed on Schedule "C" attached herewith. (a) All property co-owned by the Settlors and transferred to Trustee by the Settlors, as invested and reinvested, together with the rents, issues and profits therefrom, shall be deemed as (and retain its character as) Community property of the Settlors, subject, however to the provisions of this agreement. RLT Page 1 (of 32)PDF/22 
  • 23. (b) Sole and Separate property of either Settlor transferred to Trustee, as invested and reinvested, together with the rents, issues and profits therefrom, shall retain its character as separate property of the Settlor who transferred such property to Trustee, subject, however to the provisions of this agreement. 1.3. The Settlors shall list all of their tangible personal property on separate schedules (for each spouse), attached hereto and made a part hereof, in which they hereby direct that, at their death, Trustee shall (first) distribute and deliver such property to the persons described in such schedules to wit: the Spouses tangible personal property shall be listed on and distributed according to the "Spouses Chattel Schedule" and the Spouses tangible personal property shall be listed on and distributed according to the "Spouses Chattel Schedule". Any such Chattel distributions shall not be  deemed  as  a  part  of  the  recipient’s  portion  of  this  Trust   Estate as prescribed in Article Eight (infra) and the remainder Trust Estate – remaining after any  such  specific  “Chattel”  distributions  – shall be distributed as provided and prescribed in Article Eight (infra). 1.4. All property with a "death benefit" owned by either Settlor which is made payable to Trustee is listed on Schedule "D" attached herewith. ARTICLE TWO - Reservation of Rights - 2.1. The Settlors reserve the following rights, individually as to their respective interest in Community property and as to their respective Sole and Separate property, to be exercised at any time and from time to time by a written instrument effective immediately upon its execution during their joint lives without the consent or participation of any other person: (a) Settlors may amend this Trust, in whole or in part, or to revoke this Trust agreement in its entirety (by a writing delivered to a Trustee other than themselves if such Trustee is serving) and to remove any or all of their respective interests in their respective property transferred to this Trust. (b) Settlors may add any other property to this Trust by transferring such property to Trustee, which property shall be described in a receipt signed by Trustee, and to add any other property by their wills. Trustee shall administer and distribute any such property as if it had been a part of the original Trust assets. (c) Settlors may make payable to Trustee death benefits from insurance on their lives, annuities, retirement plans or other sources. Settlors reserve all incidents of ownership of such insurance and shall have the duties of safekeeping all documents, of giving any necessary notices, of obtaining proper beneficiary designations, of paying premiums, contributions, assessments or other charges and of maintaining any litigation. RLT Page 2 (of 32)PDF/23
  • 24. (d) Settlors may direct any Trustee as to the retention, acquisition, or disposition of any Trust assets by a writing delivered to such Trustee. Any assets retained or acquired pursuant to such directions shall be retained as a part of this Trust Estate while they are Trustee(s) unless otherwise directed in a like writing so delivered (Trustee shall not be liable to anyone for any loss resulting from any action taken in accordance with any such direction given by the Settlors). (e) Settlors may examine the records of any Trustee appointed hereunder. 2.2. A Settlors reserved powers, unless specifically provided otherwise herein or in such Settlors Will, are personal and shall not be exercisable by any other person, any guardian or any legal representative. 2.3. Upon the death of either Settlor, this Trust shall be irrevocable and not amendable subject, however, to any power of appointment, right of withdrawal or right of revocation hereinafter granted to the Survivor concerning property held in the Survivors Trust as provided in Article Five. 2.4. Notwithstanding the provisions of this Article, however, the duties, powers, liabilities and compensation of Trustee shall not be materially changed or altered without Settlors written notification to Trustee. ARTICLE THREE - Trust Administration During Settlors Lifetime - 3.1. Trustee shall hold and distribute, for the benefit of the Settlors, the principal and income of the Trust Estate out of their respective individual interests in their respective Community and Sole & Separate property as follows: (a) Trustee shall pay to the Settlors, or in accordance with their instructions, such portions of net income and principal as directed in a writing (or otherwise) delivered to Trustee. (b) Trustee shall pay to or for the benefit of the Settlors, such portions of net income and principal as Trustee, in such Trustees discretion, deems necessary or advisable to provide for their health, education, care, comfort, support, maintenance and general welfare. 3.2. Either Settlor may withdraw a portion or all of his/her Sole & Separate property and/or interest in Community property (or other jointly-held property with his/her spouse) of this Trust Estate at any time, from time to time, by a notification in writing to Trustee. RLT Page 3 (of 32)PDF/24
  • 25. ARTICLE FOUR - Administration Upon Death of First Settlor - 4.1. The remaining Trust assets not effectively disposed of by the preceding Article Three shall be allocated, administered and distributed by Trustee upon the death of the first Settlor to die, hereinafter referred to as "Decedent", as follows (the surviving Settlor shall hereinafter be referred to as "Survivor"): (a) Trustee shall pay, after a prorata designation of common debts owed by the Decedent and the Survivor respectively (e.g. one half of any common debt shall be charged equally to each spouse), his/her (first spouse to die) debts, expenses of any last illness and burial costs. (b) Such payments shall be made first out of Decedents Sole and Separate property, unless such payments would require liquidation of Decedents non-cash assets, and then out of Decedents interest in Settlors Community property, to the extent that these shall not be paid, or the responsibility for their payment be assured, by some other person or estate. 4.2. Trustee shall create three (3) separate trusts: the (1) Survivors Trust - Trust "A", the (2) Credit Shelter (Decedents Trust) Trust - Trust "B", the (3) Qualified Terminable Interest Property (QTIP) Trust - Trust "C" and apportion such Trust assets as follows: (a) Trust "A" shall consist of all of the Survivors interest in his/her Community property, Tenants-in-Common property and all of his/her Sole and Separate property. (b) Trust "B" shall consist of the largest amount, if any, of the Decedents Sole and Separate property of this Trust Estate and all of his/her interest in the Community property and any of his/her interest in Tenants-in-Common property of this Trust Estate that can pass free of federal estate tax by reason of the allowable federal unified credit and state death tax credit (provided that its use does not require an increase in the state death taxes paid) allowable after deducting the value of property disposed of by previous Articles of this trust and property passing outside of this trust that is includible in the Settlors gross estate that does not qualify for the marital or charitable deduction and after deducting charges to principal that are not allowed as deductions in computing the federal estate tax. The values finally determined for federal estate tax purposes shall be used for establishing the sums allocated pursuant to this Article. (c) Trust "C" shall consist of the remainder of the Decedents Trust Estate not allocated to Trust "B" - as determined by the formula in the previous paragraph (supra). The Decedents Executor (or the Trustee of this Trust, if appropriate) may elect, under Section 2056(b)(7) of the Internal Revenue Code as of 1986, as amended, to qualify all or any portion of the property in such Trust "C" (not otherwise designated to the Credit Shelter Trust) for the federal estate tax marital deduction as Qualified Terminable Interest Property and to be held and administered under the provisions of Article Six. RLT Page 4 (of 32)PDF/25
  • 26. (d) In making the computations necessary for determining the distributions as provided in this Article, the values finally determined for federal estate tax purposes shall be used. In the sole power and discretion of Trustee, the distributions may be either in cash or property as selected by Trustee; provided, however, that all such property so selected shall be valued at the value as finally determined for federal estate tax purposes. In allocating property, Trustee shall select assets, including cash that are fairly representative, on the date or dates of distribution, of appreciation or depreciation to determine the value of property available for distribution. (NOTE TO SETTLORS: The following Section (4.3) provides a waiver regarding the formation of the Unified Credit Shelter Trust - when specific conditions exist - as described herein. A   Trust   “B”   Apportionment   Amendment   is   available   in   the   Portfolio Administrative Documents Section that can mandate the creation of Trust “B”  regardless  that  the  aggregate  value  of  the  Trust  Estate  is  less  than  the  Federal   Exemption Equivalent amount at the date of death of the first spouse to die. If, or when, your aggregate estate exceeds One Million Dollars [$1,000,000], it is recommended  to  implement  the  Trust  “B”  Apportionment  Amendment  for  estate  tax   purposes because of the uncertainties of the federal transfer tax laws.) (Tax Elections Not Required) 4.3. NOTWITHSTANDING this Article (Paragraphs of this Article preceding this Paragraph), in the event that the total, aggregate net value of the estates of both the Spouse/Settlor and Spouse/Settlor - after including the calculation of any lifetime taxable transfers made during Settlors joint lifetimes, by either Settlor - is less than the "exemption equivalent" amount, being the amount which the Federal Unified Credit would credit against federal gift & estate transfer taxes for a individual transferor, which is then available to exempt any part of Settlors estates through the application and election of the Federal Unified Credit as defined under IRC section 2010 (as amended) and state death taxes as defined under IRC section 2011 against any transfer tax incurred as a result of any transfer of property as defined IRC section 2003, then Trustee shall not allocate any of the estate of the first Settlor to die to the Credit Shelter Trust (Trust B). (a) In such case of the Settlors total net estate value being less than the then available exemption equivalent amount, as described in Paragraph 4.3, Trustee shall transfer all of the Decedent Settlors estate directly to the Survivors Trust "A". The Survivor shall, in such case (as described above), have complete control over all Trust assets and all Trust assets shall therefore be under his/her general power of appointment as defined in IRC section 2041. (b) Upon the death of the first Settlor to die, in such case (as described in Paragraph 4.3), the Paragraphs of this Article pertaining to the division of the Trust Estate into a Decedents Trust (Trust B) and a Survivors Trust (Trust "A") (and the creation of the QTIP Trust, if needed) shall not apply. Article Five shall apply to the extent it pertains to the surviving Settlors general power of appointment over all Trust assets and Article Six (infra) shall not apply and portions of Article Seven - applicable to the Decedents Trust shall not apply. Upon the death of the Survivor, in such case, the Trust Estate shall be distributed as per Article Eight (below). RLT Page 5 (of 32)PDF/26
  • 27. (c) Notwithstanding this Section 4.3 et seq., in the event that the surviving Settlor elects to make an IRC section 2518 disclaimer regarding any allocations received from the Trust Estate of the first Settlor to die (including as per this Section), then any such disclaimed  property   shall   be  allocated/distributed  to   Trust   “B”  per  Section  4.2  (supra)  of  this   Article as though this Section 4.3 did not apply. ARTICLE FIVE - Administration/Distribution of Survivors Trust - 5.1. The Survivor shall retain full (and unhindered) general power of appointment of all property held in the Survivors Trust, including the power to alter, amend or revoke, in whole or in part, any and all provisions (including the revocation and appointment of any Trustee of the Survivors Trust) concerning such property held in the Survivors Trust. 5.2. Assets allocated to the Survivors Trust shall be valued as finally determined for federal estate tax purposes as per Article Four. 5.3. The Survivor shall have the power to direct Trustee to dispose of (and reinvest) any assets in the Survivors Trust that fail to provide income to the Survivor; all such income from the Survivors Trust shall be distributed (only) to the Survivor and at least annually or in more frequent installments, for his/her lifetime. 5.4. In the event the Survivor elects to relinquish his/her Trusteeship or becomes incapacitated as defined in this agreement, the Successor Trustee shall administer the Survivors Trust as follows: (a) Trustee shall distribute, at least annually, the net income to the Survivor in convenient installments. (b) Trustee shall, from time to time, distribute or apply for Survivors benefit such portions of the principal to provide liberally for his/her maintenance, comfort and enjoyment. (c) The Survivor may withdraw all or any portion of the Trust assets at any time by written request filed with Trustee. (Administration at Survivors Death) 5.5. Upon the death of the Survivor, Trustee shall administer and distribute any assets of the Survivors Trust (including accrued and undistributed income of the Survivors Trust) and including those assets, if any, that the Survivor may have disposed of by the last unrevoked written instruction(s) to the Trustee - including any specific directives in Survivors Last Will & Testament or Codicil to such Will (if any) - separate and apart from this Trust agreement, making specific reference to this power of appointment, exercisable alone by the Survivor and in all events, as follows: RLT Page 6 (of 32)PDF/27
  • 28. (a) Trustee may apply any assets of the Survivors Trust for the payment of (i) Survivors federal estate transfer taxes and/or state (or local) transfer/death taxes (if any); (ii) expenses of Survivors last illness, funeral, valid debts and estate administration (if any); and/or, (iii) federal estate and/or state transfer (or other local) taxes attributed to Survivors assets not held in this Trust being transferred to Survivors beneficiaries who may or may not be named or identified in this Trust as beneficiaries of this Trust. (b) Trustee shall pay any of Survivors federal, state and local transfer tax obligations, if any, that will become due at such time except any generation-skipping transfer taxes otherwise payable by a reverse qualified terminable interest property election(s) that may be established hereunder, between the Settlors, within or without this instrument. (c) All payments under the preceding provisions of this Article shall be made from the remaining (Survivors Trust) Trust assets prior to the final allocation of Trust assets to the Trust beneficiaries as provided in this agreement. (d) Notwithstanding the preceding paragraph, any assets that are to be distributed as a specific distribution, in kind, to a certain beneficiary(s) of the Survivors and/or the Decedents Trust Estate that may be described herein - shall not be used, unless otherwise provided herein, to pay expenses of either the Survivors or the Decedents Trust Estate. (e) Any assets of the Survivors Trust then remaining at the time of the Survivors death, not otherwise disposed of pursuant to Section 5.5 of this Agreement shall be distributed as per the provisions of Article Eight. ARTICLE SIX - Administration/Distribution of Trusts "B" & "C" - (Decedents Trust - Trust "B") 6.1. All administrative and distributive provisions of Trust "B", concerning property of Trust "B", may be altered or terminated by amendment, from time to time, only during the joint lifetimes of the Settlors; such amendment shall be signed by both Settlors and shall be attached hereto and made a part of this Trust agreement. 6.2. During Survivors lifetime, Trustee shall administer Trust "B" as follows: (a) Annual Income - Trustee shall pay or distribute all net income to or for the benefit of the Survivor only at such intervals as shall be mutually convenient but not less frequently than annually. (b) Necessary Support from Principal - If the Survivors Trust has been depleted to the extent that available funds are not sufficient to maintain and support the Survivor, portions of the principal may be used to provide for such Settlors maintenance and support. RLT Page 7 (of 32)PDF/28
  • 29. (c) During any period in which an Independent Trustee is serving as Trustee, it may, in its sole discretion, direct distribution of any amount of the principal to or for the benefit of the Survivor as it deems to be in Survivors best interests without limitation and without regard to the purpose or application of such distribution. 6.3. Upon the death of the Survivor, the assets of the Decedents Trust "B" shall be held, administrated and distributed as provided in Article Eight of this Agreement. (QTIP Trust - Trust "C") 6.4. During the lifetime of the Survivor, Trustee shall hold, administer and distribute the property of Trust "C" (QTIP Trust) as follows: (a) Trustee shall pay all net income, from Trust "C", to or for the benefit of the Survivor, for his/her lifetime, at such intervals that shall be mutually convenient but not less frequently than annually. The Survivor shall have the power to compel the Trustee to dispose of (and reinvest) any assets in Trust "C" that fail to provide a reasonable income to the Survivor as income beneficiary of Trust "C". Any income accrued but not distributed at the Survivors death shall be distributed to Trust "A" and be added to the principal of such trust. (b) If the Survivors resources (including property in Trust "A") have been depleted to the extent that available funds are not sufficient for such Survivors general welfare, portions of the principal, as the Trustee deems advisable, may be used to provide for Survivors health, maintenance or support. (c) During the lifetime of the Survivor, the principal of Trust "C" shall not be distributed to, or for the benefit of, any other person than the Survivor. (d) At the Survivors death, any remaining principal of Trust "C" shall be held, administrated and distributed as provided in Article Eight of this Agreement. ARTICLE SEVEN - Estate Tax Elections & Debt Allocations- 7.1. It is the main purpose and intent of this Article that, so far as is practical, any estate taxes paid shall be paid out of a decedent Settlors entire estate whether passing by this Trust instrument or outside of this Trust instrument concerning property over which a decedent Settlor possessed a general power of appointment, before distribution to any beneficiary. 7.2. If any estate (or income) tax is paid by a deceased Settlors Trustee or Executor because of any interest passing to or in the possession of any person other than the deceased Settlors Trustee or Executor, the following shall apply: (a) The Trustee or Executor shall be entitled to a just and equitable reimbursement from the beneficiary(s) of such deceased Settlors estate whose interest(s) were received, in whole or in part, outside of the possession of the Trustee or Executor. RLT Page 8 (of 32)PDF/29
  • 30. (b) Such reimbursements may be realized by the Trustee or Executor by allocating a just and equitable reduction of any portion of this Trust Estate passing to the persons whose interest in the estate of the deceased Settlor would have been otherwise reduced if the tax had been paid before the distribution of the estate or whose interest is subject to equal or prior liability for the payment of taxes, debts, or other charges against the estate. 7.3. If any part of the gross estate on which estate/transfer tax has been paid consists of the value of property included in a decedent Settlors gross estate under IRC Section 2041, the deceased Settlors Trustee or Executor shall be entitled to recover from the person (or persons, prorata if more than one recipient) receiving such property by reason of the exercise, non-exercise, or release of a power of appointment, such proportion of the total tax paid as the value of such property bears to the taxable estate. 7.4. In the case of property passing outside this Trust Estate being insurance on the life of the Settlor, with such Settlor having "incidents of ownership" on such insurance receivable by other than Trustee, Trustee shall be entitled to recover from such beneficiary such proportion of the total tax paid as the proceeds of such policies pertain to the taxable estate. If there is more than one such beneficiary, Trustee shall be entitled to recover from such beneficiaries in the same ratio respectively. 7.5. If any part of the gross estate consists of property the value of which is includible in the gross estate by reason of IRC Section 2044, relating to certain property for which a marital deduction was previously allowed, such decedent Settlors estate shall be entitled to recover from the person receiving the property the amount by which the total tax which has been paid exceeds the total tax which would have been payable if the value of such property had not been included in the gross estate. 7.6. Any assets that are to be distributed as a specific allocation/distribution - to a certain beneficiary(s) of this Trust Estate - shall not be used, nor the value thereof, to pay expenses of this Trust Estate as described in this Article. Notwithstanding, any mortgage, lien, or encumbrance on a specific devise to a certain beneficiary shall NOT BE EXONERATED, or charged against the Trust Estate, or paid by the Trustee prior to distribution but shall rather be included in any such specific allocation – unless otherwise prescribed hereunder. 7.7. Trustee may exercise all of the foregoing elections and any others available under any tax law – including the under-funding (or over-funding) of the Credit Shelter Trust as may be beneficial (to all parties of this Trust) under the terms of Rev. Proc. 2001- 38 or other (similar) law under consideration of state and/or federal transfer tax law at the time of decease of the first Settlor to die – only to obtain, to the extent practicable, both the optimum reduction in taxes estimated to be payable by a (respective) Settlors estate, this Trust, the beneficiaries of both, any business interests in the Trust Estate and the optimum deferral of all taxes. Additionally, Trustee may make adjustments between income and principal accounts and allocate the benefits from any election among the various beneficiaries of this Trust, and may compensate for the consequences of any election that Trustee believes has had the effect of directly or indirectly preferring one beneficiary or a group of beneficiaries over others. RLT Page 9 (of 32)PDF/30
  • 31. ARTICLE EIGHT - Estate Distribution Upon Death of Survivor - Trustee shall allocate the balance of the principal and accrued (but) undistributed income of Trust "A", the principal and accrued undistributed income of Trust "B" and the principal of Trust "C" referred to as the Residual Trust Estate - and distribute as follows: 8.1. Trustee shall allocate and distribute equal share values of the Trust Estate to the following named beneficiaries – HENRY J SMITH, JR, ANN B SMITH & JUSTIN F SMITH 8.2. Contingent Distributions. If any beneficiary named above does not survive the last Settlor to die then such deceased beneficiarys portion shall be distributed EQUALLY TO HIS (HER) SURVIVING LEGAL CHILDREN/ISSUE, BY RIGHT OF REPRESENTATION. If any such named beneficiary does not survive the last Settlor to die and leaves no surviving children/issue, in such case, then that decedent beneficiarys portion shall be distributed equally to the other surviving beneficiaries named above (or as otherwise may be prescribed in Section 8.6, below). 8.3. Notwithstanding the provisions defined above, Section 8.4 (below) provides a "Schedule of Other/Alternate Primary Beneficiaries" which is a list of beneficiaries (if any), and the percentages of the Trust Estate that each respective beneficiary listed thereon shall receive prior to the allocations and distributions prescribed in Section 8.1 of this Article. (a) Section 8.1 allocations – in such case of utilizing Section 8.4 – shall then be deemed as allocations of the remainder of the Trust Estate (that is) remaining after the allocations/distributions prescribed in Section 8.4. (b) If there is/are no beneficiary(s) identified above in Section 8.1 – and the beneficiaries listed in Section 8.4 (and/or   under   Section   “8.6”   /   by   Special   Directives,   if   applicable) are to receive a total aggregate of 100% of the Trust Estate (in the portions prescribed therein) – then, unless otherwise prescribed by an amendment to this trust, the allocations defined in Section 8.4 (and/or   under   Section   “8.6”   /   by   Special   Directives,   if   applicable) shall be deemed as the ONLY “Distribution Schedule(s)”  of this Trust Estate and the only allocation and distribution terms for beneficiary distributions provided herein. RLT Page 10 (of 32)PDF/31
  • 32. Alternate and/or Additional Primary Beneficiaries 8.4. Provided below is the "Schedule of Other/Alternate Primary Beneficiaries". If any beneficiary identified therein does not survive the last Settlor to die, then such decedent person’s  designated  portion  shall  be  allocated  and  distributed  to  those  other  beneficiaries  listed   below on said Schedule in prorata portions of the aggregate percentage of the Trust Estate: – SCHEDULE OF OTHER/ALTERNATE PRIMARY BENEFICIARIES – _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name 8.5. Notwithstanding the above, in the event that any beneficiary of this Trust is then a debtor to (either of) the Settlors, then the following shall apply: (a) The share of such indebted person – as verified by an instrument in writing – shall be decreased by a formula amount equal to the total outstanding debt(s) such person  owed  (either  of)  the  Settlors  (owes  to  either  of  the  Settlor’s  Trust  estate)  which  amount   is then multiplied by a percentage that corresponds to the percent of the total Trust estate – including the value of the debt(s) owed to (either of) the Settlors – that such indebted person is not entitled to receive which shall be referred to as the percentage amount. (b) The formulated percentage amount shall be subtracted from such indebted   person’s   portion   and   added   prorata to all the portion(s) distributable to the other beneficiary(s) then living. RLT Page 11 (of 32)PDF/32
  • 33. Alternate and/or Additional Specific Directives of Trust NOTICE TO SETTLORS: Use space below to enter other terms/directives that you want mandated through your Trust including but not limited to allocations, if any, to (other) beneficiaries as to distributions of "in cash" and/or "in kind": 8.6. The following terms shall ADDITIONALLY apply as to or in place of the administrative and/or allocation terms and/or decrees of this Trust notwithstanding any provisions otherwise prescribed anywhere herein to the contrary. Any allocations to beneficiaries prescribed below – whether in cash and/or in kind and/or in unequal percentage amounts – shall be deemed and administrated as part of the Schedule of Other/Alternate Primary Beneficiaries with respect to the terms of allocation/administration prescribed above: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ < < < End of Section 8.5 > > > 8.7. The following identified person(s) has/have been intentionally disinherited and is/are not to receive any portion(s) of this Trust Estate under any conditions: _________________________________________________________________ _________________________________________________________________ 8.8. Trustee shall administer and distribute those portions or shares of this Trust Estate allocated to any beneficiary (as per this Article), who has not then attained the age of twenty-one (21) years, or is legally incapacitated, at the time of death of the last Settlor to die, as per Article Ten (infra). 8.9. In the event that the foregoing provisions fail to provide for the distribution of all or any portion of the Trust Estate then such property, to the extent not distributed as per this Article, shall be distributed respectively to the living heirs-at-law of each Settlor (as to each Settlor’s   respective   interest   of   this   Trust   Estate),   as   determined by the laws of the state of domicile of the last Settlor to die at the time of his/her decease. RLT Page 12 (of 32)PDF/33
  • 34. ARTICLE NINE - Successor Trustee Appointments - 9.1. The Settlors reserve the power to remove any Trustee during their joint lives and to appoint other or additional Trustees not presently named as Successor Trustee at the creation of this Trust. 9.2. The Settlors shall serve as Co-Trustees (as heretofore appointed) until (i) they resign by a statement in writing (individually to the other Settlor or) addressed to (the successor) Trustee(s) or (ii) they are diagnosed by an attending physician as being impaired (certified in writing) beyond having the ability to manage their administrative duties of this Trust or (iii) their death. 9.3. Upon (i) resignation or (ii) inability to serve because of a medical/mental condition causing impairment of normal administrative abilities (as evidenced by a medical certificate from his/her attending physician) or (iii) death of the first Settlor to die, the other Settlor shall serve as sole Trustee. (Following is the designation of the Successor Trustee) 9.4. Upon (i) resignation or (ii) inability to serve because of a medical/mental condition causing impairment of normal administrative abilities (as evidenced by a medical certificate from his/her attending physician) or (iii) death of the surviving Settlor/Trustee, HENRY J SMITH, JR (Enter Relationship --) shall serve as Trustee of this Trust. If HENRY J SMITH, JR shall be unwilling or unable to serve as Trustee then ANN B SMITH (Enter Relationship --) shall serve as Trustee of this Trust. 9.5. In the event that no Successor Trustee Appointees are willing or able to serve as Successor Trustee as per above then the adult beneficiaries of this Trust may appoint a Successor Trustee by majority vote. (a) In the event that the adult beneficiaries are unable (in such case) to appoint a Successor Trustee within 30 days after the resignation, or incapacitation, or death of the vacating Trustee, as provided above, then the vacating Trustee, if able, may appoint a Successor Trustee; additionally, any Successor Trustee appointed by a majority vote of the adult beneficiaries may be removed at any time by a majority vote of the same. (b) If neither the vacating Successor Trustee nor the adult beneficiaries of this Trust are able to appoint a Successor Trustee then a court-appointed Successor Trustee shall serve. 9.6. If, at any time, a Settlor has been replaced as Trustee because of a voluntary relinquishment of his/her Trusteeship or by incapacity, that Settlor may re-establish his/her Trusteeship to himself/herself by executing an affidavit or notice of Trustees termination (if a Successor Trustee is then serving) and a physicians notice declaring his/her recovery if incapacitation had been (before) declared by a physician. RLT Page 13 (of 32)PDF/34
  • 35. 9.7. In the event an Individual Trustee is acting as Co-Trustee with an Independent Trustee, the Individual Trustee shall have jointly, with the Independent Trustee, all the powers given Trustee, except that the Individual Trustee shall not participate in the exercise of power or discretion to determine the propriety or amount of payment of income or principal to the Individual Trustee or to any person to whom the Individual Trustee is legally obligated, and the Independent Trustee alone shall exercise such power and discretion. 9.8. If and in the event that, at any time of incapacitation of either Settlor, as defined in this Article Nine, the Settlors State of then current domicile (or the State selected to govern the provisions of this Trust instrument by Trustee election) has as a requirement that two (or more) physicians must execute an affidavit in determining a persons legal incapacitation declaring that such person is unable to attend to his/her own fiduciary affairs because of his/her mental or physical condition, then the laws and statutes of such State shall prevail concerning such requirement. (a) Successor Trustee shall, in such case, secure two or more medical opinion letters concerning such Settlors inability to serve as Trustee. (b) Successor Trustee and transfer agents may deem the opinion letters as the required "certification of incapacitation" concerning such Settlors existing condition and may be relied upon, in all events. ARTICLE TEN - Trustee/Fiduciary Powers & Provisions - The powers hereby granted to Trustee may be exercised during the term of any Trust created hereunder. During the time after the termination of any such Trust (created hereunder) as is reasonably necessary to distribute the Trust assets, Trustee shall have all powers conferred by law to the extent not inconsistent with those stated in this document. All of Trustees powers are exercisable without any court authorization or approval to wit: TRUSTEE POWERS: 10.1. Disposition of Vested Assets. Trustee shall distribute the apportioned vested shares of principal to each beneficiary (as named) provided such beneficiary(s) has attained the age of twenty-one (21) years or older, and is not legally incapacitated. If any property of this Trust becomes distributable to a beneficiary(s) who has not attained such age or is legally incapacitated, the income (and principal, if needed) of such assets shall, unless otherwise prohibited in this Trust instrument or by Amendments attached hereto, be used and distributed for such beneficiarys health, education, maintenance and support as follows: (a) Trustee may, in its discretion, distribute portions of income (and principal, if needed) of such beneficiarys assets and/or asset account directly to such beneficiary; Trustee may distribute any remaining assets to such beneficiary if the total value of such assets is not large enough to require administration of such herein or for any other valid reason that would effectively apply at such time. RLT Page 14 (of 32)PDF/35
  • 36. (b) Trustee may, in its discretion (which shall be binding and conclusive upon all parties in interest, if made in good faith), distribute from the Trust Fund of a beneficiary - who is a minor or is legally incapacitated to any person or organization providing support for such beneficiary, the natural guardian or legally appointed guardian, conservator or other fiduciary of the beneficiary or a combination of both. Trustee is to make all such disbursements promptly for any necessities of guardianship proceedings that may apply to any beneficiary herein. (c) Trustee may distribute such assets to the beneficiarys custodian under provisions of IRC Section 2503 and the Uniform Gift to Minors Act or Uniform Transfers to Minor Act as applied under the statutes of the state-of-administration of this Trust or to such beneficiarys guardian. (d) Unless otherwise disposed of herein, if such beneficiary dies before receiving the final distribution of his/her share of this Trust Estate then Trustee may use the remaining balance of such beneficiarys share for the payment of any expenses of such deceased beneficiarys last illness, funeral or cremation or any other expenses as a result of his/her decease and shall distribute any balance remaining after payment of such expenses as provided in Article Eight of this Agreement. (e) Trustee shall not be charged to inquire into the application of any funds so paid or applied (above) and the receipt of such payee, if disbursed for such purpose in the best judgment of Trustee, shall be deemed to be full indemnification against liability to Trustee concerning such transaction(s); Trustee may, however, require such reports and take such measures as it may deem requisite to assure and to enforce the due application of such monies for the purposes aforesaid. (f) If there arises any conflict for Trustee concerning the above stated powers, as it relates to (general) powers of appointment causing unfavorable tax consequences, wherein such discretionary power to distribute may impute any principal of this Trust into his/her taxable estate that otherwise would not be imputed, then Trustee shall appoint an Independent Trustee to carry out such fiduciary provisions that may otherwise impute unintended "ownership of Trust principal" to Trustee. 10.2. Merger of Trusts. Trustee may merge the assets of this Trust or any Trust created hereunder with those of any other Trust, by whomever created, having the same beneficiaries and substantially the same terms and if there is disparity in the maximum duration of the Trusts so merged, the shortest maximum duration shall control. 10.3. Discretionary Termination. Trustee may terminate any Trust created hereunder whenever such termination is deemed advisable by such Trustee, by distributing the assets to the beneficiary to whom income may then be distributed, or if more than one beneficiary, to any beneficiary in such amounts and proportions as Trustee deems advisable, provided, however, that an Independent Trustee is then serving or if not serving, then one shall be appointed by the Individual Trustee prior to any such termination or apportionment. RLT Page 15 (of 32)PDF/36
  • 37. 10.4. Outright Distribution. If income or principal of this Trust is, by the terms of this agreement, to become part of any Trust or Trust share and would be immediately distributable, such income or principal may be distributed by Trustee in exactly the same manner as provided therein. 10.5. Distributions. Trustee may make distributions wholly or partly in cash or in specific property, real or personal, regardless of whether each resulting share/portion includes identical property and regardless of whether any resulting share/portion includes undivided interests in assets. (a) To the extent permitted by law and where not otherwise directed in this instrument, Trustee may reasonably determine the fair market value of each asset, which is distributed in kind, to distribute assets with a higher income tax basis to one beneficiary, and other assets with a lower income tax basis to another beneficiary, without making any adjustment between those beneficiaries, including making non-prorata distributions, except where otherwise directed in this instrument. (b) Trustee may sell assets which are not specifically disposed of rather than distributing them in kind for the specific purpose of minimizing the income taxes estimated to be payable by a beneficiary on sale of those assets even though doing so increases the income tax payable by this Trust. ADMINISTRATIVE PROVISIONS: 10.6. Retention of Assets. Trustee may retain any asset, however acquired, for as long as it deems advisable, even if (personally interested in the asset or) its retention results in a lack of diversification. Notwithstanding the above or any provision of this Trust that may seem contrary, if the Trust Estate is then holding "open" financial market positions – such as day trading, options trading, commodities and futures trading – generally deemed as "high beta" positions then the Trustee, or the appointed Trust Investment Advisor of this Trust (as may be applicable), shall closely monitor any such positions in relatively the same manner as was previously and customarily done by the Settlors during their lifetimes. If the Trustee, or the Trust Investment Advisor of this Trust (as may be applicable), is then unable to monitor the financial markets in such prescribed manner so as to avoid or at least mitigate related, undo losses that may occur from any such open, high beta positions then Trustee or the Trust Investment Advisor (as may be applicable) shall either close or otherwise reasonably hedge all such high beta positions in a prudent manner, as soon as possible. 10.7. Property Transaction. In the interest of the Settlors and the beneficiaries of this Trust Estate within the provisions of this Trust, Trustee may sell, exchange, mortgage, lease, convey, encumber, pledge, hypothecate or otherwise dispose of any real, personal or other property to any person, entity, beneficiary or agent or to a Trust or estate of which such Trustee is also a fiduciary, including this Trust Estate. RLT Page 16 (of 32)PDF/37
  • 38. 10.8. Investment Purchasing. Trustee may purchase (as an investment herein) assets belonging to any Trust created by a Will(s) of the Settlors or any other agreement; or lend money to this Trust Estate or to any other such Trust without personal liability of the fiduciaries thereof for repayment of such loans. Any such investments or loans are to be made at prices (upon such security, if any) and terms as may be satisfactory to Trustee; Trustee may make such investments or loans even if it is also an Executor of the Settlors Wills or a Trustee of such other Trust Estate. 10.9. Investment of Assets. Trustee may invest (or reinvest) any assets of this Trust Estate, which it deems advisable, without limitation by any statute, rule, law or regulation limiting the investment of funds by corporate or individual fiduciaries; e.g. Trustee may invest in equity funds, as well as debt securities, and may delegate investment functions. 10.10. Nominee Trusteeship. It is allowable for Trustee to hold securities or other assets of this Trust Estate in its own name, with (or without) disclosure of fiduciary capacity, or in the name of a nominee, or in bearer form. When multiple Trustees are serving, a single Trustee may deposit and withdraw funds from bank accounts, authorize transactions regarding the Trusts securities and endorse stock certificates when all other Trustees then serving have given written authorization to do so. Such authorization may be given in the signature cards or other documents establishing a bank or securities account. 10.11. Depositing of Cash. Trustee may deposit cash into the commercial or savings departments of any corporate fiduciary or of any other bank or Trust company or in any other depository. 10.12. Borrowing Monies. Trustee may borrow money for purposes it deems prudent and advisable, for the benefit of interested persons of this Trust Estate, from any source including those that it may have personal interests in. 10.13. Asset Allocation of Principal and Income. Allocations between principal and income may be made, in Trustees discretion, of all receipts and disbursements, including receipts of estate assets received or accrued during estate administration, in any manner that will not result in the loss of any available estate tax deduction. Trustee may, but need not, create reserves out of income for depreciation, obsolescence, or amortization of properties. 10.14. Division of Assets for Distribution. Trustee may divide the Trust, to determine values, to distribute like or unlike assets to different beneficiaries or Trusts and to make distributions in cash or in kind, in divided or undivided interests; provided that any assets allocated in kind in satisfaction of any pecuniary gift shall be valued at fair market value of such asset on the date of such allocation. 10.15. Direct Payments for Support. Trustee may make all payments of income or principal authorized hereunder directly to the beneficiary for the beneficiarys support, and, in the case of a beneficiary(s) who is(are) a minor or under other legal disability, all such payments (and any distributions of tangible personal property) shall be made directly to the beneficiary(s) legal guardian or conservator. RLT Page 17 (of 32)PDF/38
  • 39. 10.16. Litigation Rights. Trustee may settle, compromise, submit to arbitration or litigate claims in favor of or against the Trust. 10.17. Ascertainment of Tax Deduction Elections. Trustee may contest, settle or compromise all tax matters, to elect to claim any expense of this Trust as an income tax deduction or as an estate tax deduction, and to make any other elections authorized or permitted by law all without reimbursement or adjustment between principal and income or in favor of any beneficiary, even if the elections directly affect the value of any beneficiarys share. 10.18. Employment of Professional Assistance. Trustee is authorized to delegate and employ attorneys, accountants, investment managers, specialists and such other agents (as Trustee deems necessary or desirable) to perform ministerial duties including the appointment of an investment manager(s) to manage a portion or all (as Trustee delegates) of the assets of the Trust - thereby empowering said manager(s) the right to (i) invest such assets in their full and complete discretion, (ii) acquire and dispose of such assets, and (iii) charge any fees incurred by the employment of said agents and/or managers against the Trust with liability only for reasonable care in their selection and to place assets in an account with a Trust department of a bank. 10.19. Latitude of Trustee Power. Trustee may exercise every other power (within the limits of discretion of a prudent person) not specifically granted by this agreement that may be necessary to enable it to create, continue, operate, expand or change forms of proprietorships, partnerships, joint ventures, corporations or other businesses in conjunction with this Trust including: (a) The power to invest in any kind of property, real or personal, including shares in common Trust funds, mutual funds or open end or closed end investment funds. (b) The power to subdivide, re-subdivide, raze, alter, vacate, partition, or release real estate and any or all improvements thereon, to renew, amend, change, modify or extend leases, contract to make leases, grant options to lease, or to purchase the whole or any part of the reversion, to contract regarding the manner of fixing present or future rentals, and grant easements or changes of any kind on or with respect to such real estate. (c) The power to continue to hold and invest in, or otherwise contract to acquire any right, title or interest, real or personal, in oil, gas or other mineral property, wheresoever located, whether or not productive, including all fractional or undivided rights for whatever term(s), interest, royalties or payments, together with all options and privileges relating in any way to the exploring, drilling, mining, developing, completing, operating, improving and financing of oil, gas and other mineral property. (d) The power to receive, retain indefinitely or invest in any interest in any holding company, family investment company, general or limited partnership, proprietorship, closely held corporation or other businesses; to rely upon the audited or unaudited reports of Certified Public Accountants as to the operations and financial conditions to any such business; to elect, employ and compensate regarding any such business and to delegate to others the power to perform such acts. RLT Page 18 (of 32)PDF/39
  • 40. 10.20. Exercise of Powers and Discretions. Trustee may freely exercise any of the powers and discretions granted to it in all matters concerning the Trust Estate, after forming its judgment based upon all the circumstances of any particular situation as to the wisest and best course to pursue in the interest of the Trust and the beneficiaries, without the necessity of obtaining the consent or approval of any court. Trustee shall exercise such powers and discretions at all times in a fiduciary capacity primarily in the interests of the Trust beneficiaries. 10.21. Executing Instruments for Administration. Trustee may execute and deliver all instruments that will accomplish or facilitate the exercise of the above powers and duties and to perform all other acts necessary or advisable to administer the Trust to any corporation, transfer agent, or governmental agency and to record a copy in the office of the County Recorder of any County. 10.22. Separate Shares Management As A Unit. Trustee need not make a physical segregation of assets when dividing the Trust into shares, but may allocate undivided interests in property to such shares by an accounting procedure or may allocate different properties thereto and may administer the assets of all shares as a unit until such time as Trustee is required to make distribution. In such event, separate accounts must be kept for each Trust Estate and each share must be treated as a separate Trust for all purposes. 10.23. Risk Investments. Trustee may invest in options, futures or commodities and hold Trust securities in brokerage margin accounts if, in its discretion, such investments or holdings would seem prudent. Absent gross impropriety, Trustee shall not be held liable for any loss occurring as a result of such investments or holdings. 10.24. Insurance Premiums. Unless otherwise specified in this document, Trustee shall pay premiums on all insurance policies owned by this Trust for the duration of the policy contract. 10.25. Undivided Retention. Trustee may hold and retain the entire principal of this Trust Estate until distributions will necessitate the actual division. Trustee may hold, manage, invest and account for shares or parts thereof by appropriate entries on books of account and may allocate to each share its proportionate part of all receipts and expenses provided however that the carrying of several Trusts as one shall not differ the vesting in title or the possession of any share or part thereof. 10.26. Prorata Distributions. Trustee may make prorata distributions to any sub-trust created under the provisions of this Trust agreement whether a distribution to separate Trusts created at the death of the first Settlor to die or for distributions to the Settlors beneficiaries. 10.27. Waiver of Bonds. No bond or other indemnity shall be required of any Trustee nominated or appointed hereunder. RLT Page 19 (of 32)PDF/40
  • 41. 10.28. Waiver of Court Jurisdiction. The Settlors expressly waive any requirement that any Trust be submitted to the jurisdiction of any court, or that Trustee be appointed or confirmed or that their accounts be heard by any court. This waiver shall not prevent any Trustee or beneficiary from requesting any of these procedures. 10.29. Succession, Appointment and Removal Procedures. If a vacancy in Trusteeship occurs (voluntarily and otherwise) and a Trustee to fill such vacancy is named in this agreement or by a procedural provision in this agreement, the vacating Trustee shall promptly notify such named Successor, in writing, of the occurrence and date of the vacancy. (a) The named Trustees appointment shall become effective, following such a vacancy, upon Trustees written acceptance within thirty (30) days following the date of the vacancy. A notice of succession acceptance must be executed by the succeeding Trustee and made a part of this agreement. A copy of such notice shall be delivered to the vacating Trustee. (b) To effect the appointment of a Trustee, the person entitled to make such appointment shall file, with Trustee to be appointed, a written statement that such appointment is made. The appointment of a Trustee so appointed shall become effective upon receipt, by the person entitled to make the appointment, of the newly-appointed Trustees written acceptance within thirty (30) days following the filing of such written statement. (c) Trustee shall, upon acceptance, duly succeed to the vacating Trustees title to all of the Trust assets of the entire Trust Estate. To effect the removal of a Trustee other than the Settlors, the person entitled to remove Trustee shall either deliver to such Trustee a written statement that the removal is made, or mail such statement to Trustees last known business address by registered or certified mail, return receipt requested. After such delivery or mailing, a removed Trustee shall have no further duties, other than to account, and shall not be responsible or liable for the acts of any other Trustee. 10.30. Resignation Right. Any Trustee shall have the right to resign at any time by delivering a written resignation to those entitled to appoint a Trustee. The resignation shall be effective sixty (60) days after the date of delivery of the resignation, or upon the earlier appointment of a Trustee. After the resignation becomes effective, Trustee shall have no further duties and shall not be responsible or liable for the acts of any Trustee. 10.31. Duty to Inform and Report. If other than a Settlor is serving as Trustee, the appointed Trustee, (or Executor of any deceased Trustee) shall keep a qualified beneficiary(s) of this Trust reasonably informed as to the administration of this Trust and the material facts necessary for such beneficiaries to protect their interests. (a) Within sixty (60) days of accepting trusteeship, Trustee shall notify all qualified beneficiaries of its acceptance of trusteeship and shall provide said beneficiaries with its name, current address and current telephone number (and e-mail address if requested). RLT Page 20 (of 32)PDF/41
  • 42. (b) Within sixty (60) days after the date Trustee acquires knowledge of this Trust becoming irrevocable whether by the death of the Settlor(s) or otherwise, Trustee shall notify  the  qualified  beneficiaries  of  the  Trust’s  existence,  of  the  identity of the Settlors, of the right   to   request   a   copy   of   the   Trust   instrument,   of   the   right   to   a   Trustee’s   report   as   provided   herein, and shall notify the qualified beneficiaries in advance of any change in the method or rate  of  Trustee’s  compensation. (c) Upon request (only) by the interested parties (distributees), Trustee shall send to the distributees and permissible distributees of Trust income or principal, and to other qualified or nonqualified beneficiaries, at least annually and at the termination of the Trust, a report of the Trust property, liabilities, receipts, and disbursements, including the source and amount   of   the   Trustee’s   compensation,   a   listing   of   the   Trust   assets   and,   if   feasible,   their   respective market values. To the extent possible and reasonable, Trustee shall be allowed to allocate   the   expense   (a   portion   of   Trustee’s   fees)   directly   to   the   requesting   beneficiary’s   (capital) account prorata relative to the time/expense of providing such (accounting) report(s) to any such requesting beneficiary and, as applicable, may withdraw the expense of administration thereof from such account(s). (d) Upon vacancy in a trusteeship, unless a Co-Trustee remains in office, a report must be sent to the qualified beneficiaries by the former Trustee (or   that   Trustee’s   personal representative, conservator or guardian on behalf of the deceased or incapacitated Trustee). (e) The “report” as described herein, may be informal in nature and can be accomplished by copies of tax returns, brokerage statements and the like; the approval of these accounts by those persons, in writings delivered to any Trustee, shall constitute a valid and effective release of such Trustee with respect to all transactions disclosed by the accounts, and shall be binding and conclusive as to all persons. (f) Notwithstanding the above, a beneficiary(s) may waive the right to a Trustee’s  report  or  other  information  otherwise  required  to  be  furnished  under  this  section;;  and   the beneficiary may subsequently withdraw such waiver with respect to future reports and other information. (g) For  purposes  of  this  section,  the  term   “qualified  beneficiary”  is  defined   as (i) a charitable entity and/or (ii) a natural person who has obtained the age of 25 years either being vested – as in having legally equitable rights through the terms of this Trust because of an event described herein that has (already) happened – as to the income and/or principal distributions of this Trust. 10.32. Majority Vote and Delegation. If more than one Trustee is serving, their powers shall be exercisable by a majority vote of Trustee authorized to act. If such occurs the other Trustee shall not be responsible or liable to any person, in their capacities as Trustee, for the administration of the Trust during the time such delegation is in effect. 10.33. Custody of Assets. If a corporate Trustee is nominated to serve by any Trustee, it shall have custody of all assets, handle receipts and disbursements and prepare accountings. RLT Page 21 (of 32)PDF/42
  • 43. 10.34. Change of Trust Situs. Trustee may transfer situs of the administration of any Trust created hereunder from the Settlors state of domicile to Trustees state of domicile and may elect, in its discretion, to have the governing laws of such state apply to this Trust instrument. 10.35. Income at Termination. Unless such income is expressly made subject to an income beneficiarys general power of appointment, any accrued or undistributed income at the termination of a Trust with a sole income beneficiary shall be distributed to such beneficiary, or if the beneficiary is deceased, to the beneficiarys estate unless otherwise disposed of herein; in all other cases, such income shall be added to principal. 10.36. "S" Corporation Election. Any "S" corporation stock transferred to this trust may continue to be treated as an "S" election corporation to the extent allowable and pursuant to the Internal Revenue Code of 1986, as amended. In such case, any beneficiarys share that may be vested with any "S" corporation stock, pursuant to the distribution provisions of this Trust Agreement, shall be administered by Trustee, as pertaining to such "S" stock, as follows: (a) All income from such "S" corporation stock must be distributed at least annually to such beneficiary of that beneficiarys prorata portion of the Trust Estate consisting of such "S" corporation stock. (b) All such stock interest must be distributed to such beneficiary upon the termination of this Trust if such beneficiary is then living. (c) Notwithstanding the above provisions to the contrary, the Trustee may, in its discretion, implement the "electing small business trust" (ESBT) federal code pursuant to the terms of IRC Section §1361(e)(1) at any time to all or part of this Trust Agreement pursuant to "S" corporation stock transferred herein on behalf of the designated, permitted beneficiary(s) named herein. If the ESBT election is made, Trustee shall not make any ESBT elections on behalf of any beneficiary of this Trust unless such beneficiary(s) is a "permitted beneficiary" as prescribed Section §1361 (e)(1)(A) and Treasury Regulation Section 1.1361-1(m)(2)(ii). (d) Notwithstanding,   if   at   any   time   any   shares   of   a   “S”   Corporation   as   defined in Subchapter S of the Internal Revenue Code and set forth in Sections §1361 through §1379, as amended, are held in this Trust and it is deemed that the provisions herein preclude this   Trust   from   qualifying   as   a   trust   permitted   as   a   shareholder   of   “S”   Corporation   stock   pursuant to Section §1361(c)(2) regarding an ESBT, then the living/existing beneficiary(s) of such  trust  and  the  “S”  Corporation  stock  allocated  to   each such beneficiary shall be held as a separate   trust,   hereinafter   referred   to   as   a   “Qualified Subchapter S Trust" (QSST) and administered under the terms and rules prescribed therein. (e) It  is  the  Settlors’  intent  that  no  QSST  created  hereunder  is  administered   in  such  a  manner  as  to  cause  the  termination  of  the  “S”  Corporation  status  of  any  corporation   whose stock is held in such QSST. Accordingly, to the extent that the terms of this Trust Agreement are inconsistent with any trust created hereunder that qualify as a QSST for federal income  tax  purposes,  it  is  Settlors’  intent  that  the  terms  of  the  QSST  be  nullified. RLT Page 22 (of 32)PDF/43
  • 44. 10.37. Authenticity and Notices. Trustee may rely on any information or document, believed to be genuine, without incurring liability for any action or inaction based thereon. Unless Trustee receives written notice of any birth, marriage, death or other event upon which the right to payments from the Trust Estates may depend, Trustee shall incur no liability for disbursements made in good faith to persons whose interests may have been affected by that event. 10.38. Investigation not required. No person or corporation dealing with Trustee shall be required to investigate Trustees authority for entering into any transaction or to see to the application of the proceeds of any transaction. 10.39. Trustee-Installed Amendments. Trustee may, upon giving notice to each beneficiary, amend, either in whole or in part, any administrative provision of this Trust which causes unanticipated tax liability, or conform the administrative provisions of this Trust to the requirements of the taxing authorities, as well as any particular state law requirements applicable thereto. Trustee is, therefore, expressly authorized to enter into any agreements with the Internal Revenue Service or any other governmental body and to execute any documents as will, in Trustees discretion, tend to minimize the taxes resulting from this Trust. 10.40. Surviving Settlors Occupancy. Unless otherwise expressly provided herein to the contrary, the surviving Settlor shall be allowed to occupy and use Settlors primary residence, or his/her interest therein, until surviving Settlors death or long-term absence (of 120 days or longer) because of nursing home, or other long-term health care requirements. (a) Unless otherwise provided, the surviving Settlor may direct Trustee to sell such residence and purchase another comparable residence for the surviving Settlors use; if the surviving Settlors children are not the same as the decedent Settlors children then the surviving Settlor must have the unanimous permission of the decedent Settlors children prior to the Trustees sale of such residence. (b) All taxes, insurance, repairs and assessments concerning such residence shall, unless otherwise stated herein, be paid out of the decedent Settlors Trust Estate and the surviving Settlors Trust Estate - prorata to and by their respective interest in this Trust Estate. 10.41. Qualified Designated Beneficiary Trust. For the specific purposes of employing terms and provisions required to qualify this Trust as a "Designated Beneficiary Trust" so as to optimally utilize the minimum distribution rules for qualified plan allocations/distributions as defined in Title 26 USC § 401(a)(9) and the separate accounts rule as determined under CFR § 1.401(a)(9)-8, A-2(a)(2), the following shall apply: (a) Unless otherwise determined by specific provisions in this Trust, Trustee shall satisfy any allocation(s) herein to any charity or other statutory entity - including, but not limited to, estates, corporations, and partnerships - by distributing such charitable or other statutory-entity allocation(s) in its entirety prior to September 30th of the year following the year of the surviving Settlors death. RLT Page 23 (of 32)PDF/44
  • 45. (i) Concerning the Trust Estate of the first Settlor to die, such statutory-beneficiary distributions as described above shall be made prior to September 30th of the year of death of the first Settlor to die relative to that decedent Settlors Trust Estate. (ii) The above paragraph shall apply whenever the clear intent of the dispositive and administrative terms herein is to maximize the minimum distribution rules for the benefit of such decedent (first spouse to die) Settlors beneficiaries as specifically allowable for non-spouse allocations of qualified retirement plan assets. (b) Unless otherwise specifically determined herein, in no event shall any allocation(s)/distribution(s) to charitable or other statutory-entity (non-natural) beneficiaries from this Trust Estate be comprised of qualified retirement plan assets. (c) Trustee shall present this Trust, or a certified copy hereof, to the relevant qualified retirement plan provider(s) no later than October 31st of that same year referred to in the (immediate) above paragraphs to identify and certify the qualified beneficiaries of this Trust prior to September 30th of that same year. (d) Taking into account the potential cost(s) to the Trust Estate for accounting and other administrative procedures compared to the long-term (tax-deferred) benefits that may be derived for the beneficiaries of this Trust, it is the intent of the Settlors to reasonably maximize the minimum distribution rules as defined in Title 26 USC § 401(a)(9) and the separate accounts rule as determined under CFR § 1.401(a)(9)-8, A-2(a)(2) to the extent where any age-based allocations of qualified plan assets of this Trust are best served by maximizing the benefit of the minimum distribution rules on behalf of each individual beneficiary. (i) Relative to such cases, Trustee shall establish separate trust accounts for each beneficiary then vested to receive qualified plan distributions over an age- based allocation period(s) established hereunder for each beneficiary and shall also procure a separate Tax ID number(s) - as appropriate and if deemed necessary - for each separate trust account. (ii) Any establishment of separate trusts herein for each individual beneficiary for the purposes of maximizing the minimum distributions rules for the benefit of each retirement plan beneficiary of this Trust shall be reported to the relevant retirement plan provider(s) for their accounting and allocation purposes. RLT Page 24 (of 32)PDF/45
  • 46. ARTICLE ELEVEN - General Governing Provisions - DEFINITIONS OF TRUST: 11.1. Descendants/Issue. "Descendants" or "issue" are those persons who are lineally descended from the same bloodline of a parent or ancestor (including legally adopted lineal descendants) except illegitimate descendants and their descendants and shall mean in this Trust instrument, unless otherwise defined, as second generation to the Settlors. 11.2. Child. "Child" means a child of the Settlors unless expressly referred to otherwise. 11.3. Per Stirpes. "Per stirpes" means distribution of a certain portion or share (of this Trust Estate) in equal shares among surviving issue of the Decedent person who would have otherwise received a portion of this Trust Estate and referred to by right of representation and not as so many Individuals. 11.4. Per Capita. "Per capita" means a distribution in equal shares to a number of persons, all of whom stand in equal degree to the Decedent (who would have otherwise received such share), without reference to their assets or the right of representation. 11.5. Descendant in Gestation. A descendant in gestation at the time of an event is later born alive and is "living/surviving" at the time of such event. 11.6. Simultaneous Death. If the Settlors shall die simultaneously or under circumstances which make it difficult to determine with reasonable certainty which of them died first, the Settlor with the smallest federal adjusted gross estate shall be deemed to have survived for the purpose of this instrument and the provisions of this instrument shall be construed upon that assumption, irrespective of any provision of law establishing a contrary presumption or requiring survivorship for a fixed period. (a) Notwithstanding the preceding paragraph, however, in the event that the value of the Trust Estate is equally owned and/or each Settlors property equals a value exceeding the amount of property effectively exempted by the then allowable Unified Credit against the federal estate tax (adjusted for lifetime taxable gifts) then available to each such Settlor, then the Settlors, under such circumstances, shall be deemed to have died simultaneously. (b) In such simultaneous deaths of Spouse & Spouse as Settlors with equal interest in their respective estates, Trustee shall not then qualify any portion of either Settlors estate for the Federal Estate Tax Marital Deduction. 11.7. Trustee. "Trustee" means an original or any Trustee of any Trust hereunder, and may include Individuals and corporations. 11.8. Independent Trustee. "Independent Trustee" means any Trustee other than: RLT Page 25 (of 32)PDF/46
  • 47. (a) a Trustee who is a beneficiary to whom income or principal could be distributed currently; or, (b) a Trustee who has a legal obligation to support a beneficiary to whom income or principal could be distributed currently. 11.9. Corporate Trustee. "Corporate Trustee" means any qualified Trust company or national or state banking institution having Trust or fiduciary powers governed by its state of situs. 11.10. Mandated Documents. The requirement that a person act in writing requires a dated written document signed by such person. 11.11. Physician. Unless otherwise identified in writing delivered to any Trustee by the Settlors, the "family or attending physician" shall be deemed to be the physician to whom the Settlor(s) has been attended by prior to the date of execution of such physicians Medical Certification or "opinion letter" according to terms heretofore stated. 11.12. Tax to Second Generation. "Generation-skipping tax" means any state or federal tax imposed on a generation-skipping transfer. 11.13. Gender. Where appropriate, the masculine includes the feminine, the singular includes the plural, either includes the neuter and vice versa. RULES OF CONSTRUCTION: 11.14. Laws Governing Trusteeship and Taxation. All questions pertaining to the validity of any Trust created hereunder or its terms shall be determined in accordance with the laws of whatever state having sufficient connection with such Trust that will support the validity of such Trust. (a) All other determinations shall be governed by the laws of the State in which this Trust is then being administered based on situs of the office of Trustee (or an elected office by Trustee if more than one is serving at one time) then having custody of that Trusts principal assets and records. (b) The foregoing shall apply even though the situs of Trust assets or the domicile of the Settlors, Trustee or a beneficiary may be elsewhere. (c) Except where (or when) otherwise required, this Trust shall not be registered under the laws of the State of Arizona or any other jurisdiction. 11.15. Captions. Captions are for convenience only and are not intended nor used to alter any of the provisions or intent of this document. If any portion of this Trust is held to be void or unenforceable, the balance shall, nevertheless, be carried into effect. RLT Page 26 (of 32)PDF/47
  • 48. PROTECTIVE PROVISIONS: 11.16. Marital Deduction. All provisions of this agreement shall be construed and applied so that any gifts between spouses qualify for the federal and state (of domicile) marital deduction and that the Survivors Trust can qualify for the federal marital deduction, and any provision of this agreement incapable of being so construed or applied shall not apply to such gifts. The Survivor shall have the power to require Trustee of the Survivors Trust to render any asset of such Trust productive of income. 11.17. Taxation Exemptions. No part of any benefits payable to or receivable by any Trustee hereunder from qualified pension, profit sharing or retirement plans that may be exempt from taxation under Section 2039 of the Internal Revenue Code shall be directly or indirectly applied to the payment or reimbursement of any estate, succession or other death taxes or of the expenses, debts, and other items required to be paid by any Trustee. 11.18. Non-Liability of Individual Trustee. No (Individual) Trustee who has acted in good faith shall be liable for the acts of any Co-Trustee (if such is named) or for failure to assert breaches of Trust by a deceased, resigned or removed Trustee. 11.19. Spendthrift Provision. Neither principal nor income of any Trust share hereunder nor any beneficiarys interest therein shall be subject to alienation, assignment, encumbrance, appointment or anticipation by the beneficiary, to garnishment, attachment, execution of bankruptcy proceedings, to claims for alimony or support or any other claims of any creditor or other person against the beneficiary or to any other transfer, voluntary or involuntary, to or from any beneficiary (provided that the foregoing shall not restrict the exercise of any power of appointment and that any principal distributable to any beneficiary by reason of having attained a specified age shall be fully alienable by such beneficiary after attaining such age). Notwithstanding the preceding sentence, the provisions of the preceding sentence shall not apply under any conditions where there may be an adverse impact on marital deduction elections under IRC Section 2056. 11.20. Special Powers of Appointment. Any special power of appointment may be exercised by appointment, outright or in Trust, to one or more of the permissible appointees in such portions as the holder of the power may appoint; provided: (a) the power shall not be exercisable in favor of the holder, the holders estate, the holders creditors or the estate of the holders creditors, and; (b) It shall not include the power to create another power of appointment that, under the applicable local law, can be exercised so as to postpone the vesting of any estate or interest in the Trust property or suspend the absolute ownership or power of alienation of such Trust property for a period ascertainable without regard to the date of creation of this power. RLT Page 27 (of 32)PDF/48
  • 49. 11.21. Rule Against Perpetuities. All Trusts created hereunder, if not sooner terminated pursuant to the provisions hereof, shall terminate twenty-one (21) years, plus gestation period if applicable, after the death of the last surviving beneficiary (or designated descendent) who is then living at the time of the effective date of this Trust or the effective date of any Trusts created hereunder; the "effective date" of this Trust or Trusts created hereunder means the date that this Trust or any Trusts created hereunder become(s) irrevocable because of the death(s) of the Settlor(s) of such Trust(s). (a) Any Trust assets governed by a statute or rule of law under which such assets could not validly remain in Trust until that date shall be distributed on the last date on which such assets can validly remain in Trust. (b) In the event of termination of a Trust in whole or in part under this provision, the Trust assets shall be distributed to the beneficiaries who were permissible recipients of Trust income immediately prior to such termination. 11.22. Compensation for Trustee. All Trustees of this Trust, whether an Independent Trustee, corporate Trustee or a beneficiary (Trustee), shall be allowed to receive, from readily available Trust assets, a reasonable compensation for their administrative duties and services. Any such compensation shall not exceed the amount customarily charged by corporate fiduciaries for similar services. 11.23. Invalidity of Provisions. If any provision of this instrument be invalid, no Trust shall fail but shall continue and be administered as if such provision did not appear. 11.24. No-Contest Clause. If any (a) beneficiary under this trust, (b) devisee, legatee or beneficiary  under  either  Settlor’s Will, (c) heir of either Settlor, or (d) person claiming under either  this  trust  or  either  Settlor’s  estate  or  any  other  trust  established  by  either  Settlor  legally   contests   this   Trust   or   any   of   the   provisions   stated   herein,   then   such   person’s   portion   of this Trust shall be forever forfeited and such person shall be deemed as though he/she did not survive the last Settlor to die and left no surviving children. 11.25. Disinheritance. Except for those persons expressly identified in this Trust either by name or reference whether born or unborn, Settlors have intentionally omitted to provide for   any   other   persons   who   may   be   either   or   both   of   Settlors’   relatives   or   other   associations,   whether or not now in being. ARTICLE TWELVE - Life Insurance Payable to Trustee - 12.1. Trustee, acting as such, is not responsible for the payment of premiums or other assessments on any life insurance policies on the live(s) of the Settlor(s) with regards to policies having death benefits payable to the Trustee or to other beneficiaries unless, however, the subject policies owned by the Settlor(s) are then being paid from an account respectively held in this Trust. RLT Page 28 (of 32)PDF/49
  • 50. 12.2. Upon the death of the insured thereunder, Trustee shall take any action necessary to collect any and all insurance policy proceeds and is authorized to pay the expense therefrom out of a decedent/Settlors Trust Estate. Trustee may release the insurance company from its liability under the policy and accept a compromise deemed necessary for the timely and proper collection of insurance proceeds. 12.3. Trustees receipt, delivered to the insurance company, of policy proceeds from the insurance company shall constitute a complete release for such insurance company for any payment concerning such receipt and shall bind the beneficiaries of this Trust Estate. 12.4. After deducting all charges of the insurance policy concerning advances, loans or other debts, Trustee shall distribute the proceeds of the policy according to the dispositive provisions of this Trust Estate and according to the legal ownership of the policy. (a) Any insurance policy for which its premiums were paid out of Community property assets shall retain its character as Community property and shall be valued and distributed as such in accordance with the dispositive provisions of the Community property of this Trust. (b) Any insurance policy for which its premiums were paid out of sole and separate property shall retain its character as sole and separate property and shall be valued and distributed as such in accordance with the dispositive provisions of the respective sole and separate property of the respective Decedent/Settlor. 12.5. Unless a policy is owned by this Trust, the designation of a person other than Trustee as beneficiary of any such policy shall cause the proceeds of such policy to pass outside the terms and conditions of this Trust (unless otherwise referenced hereto) and not be a part of this Trust with respect to such policy or any benefit thereof and shall release Trustee from all responsibility in connection with that policy. ARTICLE THIRTEEN - Administration of Professional Corporation - 13.1. Notwithstanding the provisions of this Trust agreement concerning the administration of the assets herein by the named Trustee(s), the following provisions shall govern those assets transferred to this Trust Estate designated as stock of a Professional Corporation, as defined under the laws of the state of domicile of the Settlors, created by and for an Individual(s) rendering professional services requiring a license to perform such and allowing such Individual to own shares of stock in such corporation: 13.2. Notwithstanding that any stock of a Professional Corporation, as defined under the laws of the state of domicile of the Settlors, which is transferred to this Trust Estate is co- owned, all stock of such corporation shall be under the administration of the shareholder who is licensed to provide the services performed by the corporation as sole Trustee and not as Co- Trustee with his/her Spouse during such owners lifetime. RLT Page 29 (of 32)PDF/50
  • 51. 13.3. In the event the titled owner of such stock shall be the first spouse to die, then the Trustee of this Trust Estate shall be vested title of such stock as according to the provisions of this Trust instrument and shall act within the limits set by State law to formulate administration of or sale to another professional holding the same certificate of license granting authorization to perform such services. 13.4. Proceeds of any transactions of the preceding paragraph shall be distributed and administrated, in prorata designations or otherwise, under the provisions of this Trust agreement according to such property designation whether separately or co-owned as under State (of domicile) law or previous agreement between the Settlors of this Trust agreement. 13.5. Any "non-licensed" surviving Settlor/Spouse shall have equitable title as to the shares of such corporation not to exceed his/her interest in community or other jointly owned property vested to hxm/hxr by state (of domicile) law. Additionally, any remainder beneficiaries of this Trust shall have interest in such corporation limited to the proceeds from the sale of such corporation shares after the death of the licensed/Settlor/Trustee. 13.6. Any beneficiary of this Trust Estate shall have beneficial interest only (in values previously determined in this Agreement) to proceeds from a sale of the shares of the Professional Corporation, held in this Trust, and not equitable title to those shares. ARTICLE FOURTEEN - Non-Liability of Separate Parties - Custodial agents, transfer agents, venders, financial institutions, physicians or any other "separate parties" (of this Trust) performing fiduciary or transferal duties or rendering any other service, pursuant to any such transfers, documents etc., for the furtherance of the purposes and intents of this Trust shall, absent of any fraud, be under no liability or obligations for the application or administration of this Trust, and shall not put Trustee to task or inquiry regarding any supplements or amendments of this Trust, which may have been created and executed by the Settlors from time to time, other than such supplements and amendments that Trustee alone shall present to any separate party. ARTICLE FIFTEEN - Certificate of Trust Proving Existence - A Certificate of Trust signed by the Settlors of this Trust agreement and acknowledged before a Notary Public shall be conclusive evidence upon all persons and for all purposes of the facts stated in said Certificate respecting the terms of this Trust agreement and of the text thereof and of who are, from time to time, Trustees hereunder. RLT Page 30 (of 32)PDF/51
  • 52. ARTICLE SIXTEEN - Transmutation of Assets on Contingency - 16.1. If either Settlor becomes medically or mentally incapacitated so as to require skilled nursing care, intermediate care or custodial care as defined by state of domicile statutes, Trustee may transmute any community (or any other jointly owned) property held in this Trust agreement into sole and separate property respectively. 16.2. Prior to any such transmutation, however, Trustee shall first determine, in its discretion, that any potential capital gains tax consequences of the transmutation of community property to separate property including without limitation the loss of the potential "step-up" in basis as provided in IRC §1014(b)(6) are outweighed by the benefits of transmuting property from community property to separate property. 16.3. Any such transmutation of community or other jointly owned assets shall be effected by Trustee only under the following conditions: If Settlors combined estate is equal to or less than the amount currently allowed by the Settlors resident state to be retained by a well spouse and not to be spent down as a result of financial liability of the ill spouse, then Trustee may transfer the ill spouses share (one-half of the sum allowable to keep from a spend down) to the well spouse. Any Separate property which became such as a result of the provisions of this Article shall, however, become Community (or otherwise jointly owned) property immediately upon the request of both spouses at the recovery of such ill spouse. Recovery shall, by definition, mean that the ill spouse is no longer requiring institutionalized care as defined by this Article. In exercising any provisions allowed by this Article, Trustee shall first determine if any immediate or potential tax losses (or other losses) would occur as a result of the implementation of such transmutation of property as defined by this Article and act in accordance with such determinations, whether favorable or unfavorable, concerning the beneficiaries of this Trust. RLT Page 31 (of 32)PDF/52
  • 53. ACKNOWLEDGEMENT We, HENRY J. SMITH & MARY A SMITH, the undersigned Settlors of this Revocable Living Trust Agreement referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 hereby sign our names to this instrument on this ______ day of _______________, 2012, and being first duly sworn, declare to the undersigned authority that we sign and execute this instrument willingly, consisting of thirty-two (32) pages including this page, and execute it as our free and voluntary act for the purposes herein expressed, and that we are eighteen years of age or older, of sound mind, and under no constraint or undue influence. x______________________________ x______________________________ HENRY J. SMITH MARY A SMITH (AFFIDAVIT OF WITNESSES) We, __________________________ & __________________________, the witnesses, hereby sign our names to this instrument, being first duly sworn, and declare to the undersigned authority that HENRY J. SMITH & MARY A SMITH signed and executed this instrument before us and that they signed it willingly and that each of us hereby signs as a witness and acknowledgement to their signing, and that to our knowledge they are of eighteen years of age or older, of sound mind, and under no constraint or undue influence. x________________________________ _______________________________ Witness Address x________________________________ _______________________________ Witness Address On this ______ day of ________________, 2012, before me, ___________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH and the above identified WITNESSES, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed the same in their authorized capacity and by their signatures. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: _____________________________ (Seal) RLT Page 32 (of 32)PDF/53
  • 54. LOCATER/IDENTIFIER REFERENCE LEDGER SMITH FAMILY TRUST Listed below are names, w/relationships (to Settlors), addresses and phone numbers of individuals who are parties of the Trust including beneficiaries, trustees, personal representatives, agents, and/or guardians. Individual Address/Phone _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________PDF/54
  • 55. LOCATER/IDENTIFIER REFERENCE LEDGER SMITH FAMILY TRUST Listed below are names, w/relationships (to Settlors), addresses and phone numbers of individuals who are parties of the Trust including beneficiaries, trustees, personal representatives, agents, and/or guardians. Individual Address/Phone _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________PDF/55
  • 56. CERTIFICATE OF TRUST Introduction This fourth section contains the Certificate of Trust. This document is primarily for providing evidence to a transfer agent about certain facts concerning your trust. A transfer agent is an agent authorized by your trust (and as shown in this Certificate of Trust) to rely on the information provided in this certificate as being evidence sufficient to enable hxm/hxr to make a transfer of your assets, held on account with his/her firm, to your trust. This certificate shows to the agent that (1) you have established a trust, as creators/settlors, on a certain date, (2) you have retained revocable power over the trust, (3) you are (currently) serving as trustee, (4) a successor will be serving as trustee at a later time, based on a contingent event and (5) basic administrative powers have been granted to the trustee. It is not necessary for you to disclose to any outside party the persons and methods you have chosen to disperse your estate to and by. Therefore, a certain amount of privacy, as well as convenience, can be maintained by furnishing a Certificate of Trust to transfer agents instead of the actual trust itself. You may need to make several copies of this document, depending on how many agents you will be dealing with. Reproductions (copies) are deemed to be original counterparts of the certificate itself so it is not necessary for the agent to see the original document he/she needs to have only a copy. For your convenience, two original Certificates of Trust will be provided in this Section. It is generally not necessary to send a copy of this document to the county recorders office when recording deeds. It must, however, be used in conjunction with the Retitlement & Change of Beneficiary Letters and Stock & Bond Powers (located in the tenth section). Both spouses need to sign this document in the presence of a Notary Public. _______________PDF/56
  • 57. CERTIFICATE OF TRUST TO WHOM IT CONCERNS: THIS CERTIFIES that HENRY J. SMITH & MARY A SMITH, on the date indicated below, created and established a Revocable Living Trust and appointed HENRY J. SMITH & MARY A SMITH as Trustee(s) of said Trust acknowledged and referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 Any other designation of Trustee(s) of said Trust is valid, and to be recognized by whom it concerns, when evidenced by the contents of this instrument (or altered by a valid amendment thereof) and a "SUCCESSOR TRUSTEE NOTICE" (and proper appendage) attached to this Certificate. Any designated Trustee(s) hereunder shall act with full delegated powers stated herein on its own, being sufficient and therefore unnecessary to be put to further inquiry into the right of such Trustee to so act. Reproductions of this executed original shall be deemed to be original counterparts of this Certificate. The undersigned hereby certify that the following constitutes a true and correct statement of certain provisions in said Trust and may be relied upon of the matters covered by such provisions: ARTICLE TWO - Reservation of Rights - 1. The Settlors reserve the following rights, jointly as to their Community property and Individually as to their respective Separate property, to be exercised at any time and from time to time by a writing of instrument effective immediately upon its execution during their joint lives without the consent or participation of any other person: 1.1. To amend said Trust, in whole or in part, or to revoke this Trust agreement in its entirety (by a writing delivered to a Trustee other than themselves if such Trustee is serving) and to remove any property previously transferred to said Trust. 1.2. To add any other property to said Trust by transferring such property to Trustee, which property shall be described in a receipt signed by Trustee, and to add any other property by their wills. Trustee shall administer and distribute any such property as if it had been a part of the original Trust assets. 1.3. To make payable to Trustee, death benefits from insurance on their lives, annuities, retirement plans or other sources. The Settlors reserve all incidents of ownership; and shall have the duties of safekeeping all documents, of giving any necessary notices, of obtaining proper beneficiary designations, of paying premiums, contributions, assessments or other charges and of maintaining any litigation. 1.4. To direct any Trustee as to the retention, acquisition, or disposition of any Trust assets by a writing delivered to such Trustee. Any assets retained or acquired pursuant to such directions shall be retained as a part of this Trust estate unless otherwise directed in a like writing so delivered. Trustee shall not be liable to anyone for any loss resulting from any action taken in accordance with any such direction given to them by the Settlors. COT Page 1 (of 5)PDF/57 
  • 58. 2. A Settlors reserved powers, unless specifically provided otherwise herein or in such Settlors Will, are personal and shall not be exercisable by any other person, any guardian or any legal representative. 3. Upon the death of either Settlor, this Trust shall be irrevocable subject, however, to any power of appointment, right of withdrawal or right of revocation hereinafter granted to the Survivor (infra) concerning property held in the Survivors Trust (infra). 4. Notwithstanding the provisions of this Article, however, the duties, powers, liabilities and compensation of Trustee shall not be materially changed or altered without Settlors written notification to Trustee. ARTICLE NINE - Successor Trustee Appointments - 1. The Settlors reserve the power to remove any Trustee during their joint lives and to appoint other or additional Trustee not presently named as Successor Trustee. 2. The Settlors shall serve as Co-Trustees (as heretofore appointed) until (i) they resign by a statement in writing (individually to the other Settlor or) addressed to Trustee(s) or (ii) they are diagnosed by an attending physician as being impaired (certified in writing) beyond having the ability to manage their administrative duties of this Trust or (iii) their death. 3. Upon (i) resignation or (ii) inability to serve because of a medical/mental condition causing impairment of normal administrative abilities (as evidenced by a medical certificate from his/her attending physicians) or (iii) death of the first Settlor to die, the other Settlor shall serve as sole Trustee. 4. Upon (i) resignation or (ii) inability to serve because of a medical/mental condition causing impairment of normal administrative abilities (as evidenced by a medical certificate from his/her attending physician) or (iii) death of the surviving Settlor/Trustee, HENRY J SMITH, JR (Enter Relationship --) shall serve as Trustee of this Trust. If HENRY J SMITH, JR shall be unwilling or unable to serve as Trustee then ANN B SMITH (Enter Relationship --) shall serve as Trustee of this Trust. ARTICLE TEN - Trustee Fiduciary Powers & Provisions - 1. Retention of Assets. Trustee may retain any asset, for as long as it deems advisable, even if (personal interest) its retention results in a lack of diversification. 2. Property Transaction. Trustee may sell, exchange, mortgage, lease, convey, encumber, pledge, hypothecate or otherwise dispose of any real, personal or other property to any person, entity, beneficiary or agent or to a Trust or estate of which such Trustee is also a fiduciary, including this Trust estate. 3. Investment Purchasing. Trustee may purchase (as an investment for this Trust estate) assets belonging to any Trust created by a Will(s) of the Settlors or any other agreement; or lend money to this Trust estate or to any other such Trust without personal liability of the fiduciaries thereof for repayment of such loans. Any such investments or loans are to be made at prices (upon such security, if any) and terms as may be satisfactory to Trustee; Trustee may make such investments or loans even if it is also an Executor of the Settlors Wills or a Trustee of such other estate. COT Page 2 (of 5)PDF/58
  • 59. 4. Investment of Assets. Trustee may invest (or reinvest) any assets of this Trust estate, which it deems advisable, without limitation by any statute, rule, law or regulation limiting the investment of funds by corporate or individual fiduciaries; Trustee may invest in equity and debt securities and may delegate investment functions or commingle assets. 5. Nominee Trusteeship. It is allowable for Trustee to hold securities or other assets of this Trust estate in its own name, with (or without) disclosure of fiduciary capacity, or in the name of a nominee, or in bearer form. When multiple Trustees are serving, a single Trustee may deposit and withdraw funds from bank accounts, authorize transactions regarding the Trusts securities and endorse stock certificates when all other Trustees then serving have given written authorization to do so. Such authorization may be given in the signature cards or other documents establishing a bank or securities account. 6. Depositing of Cash. Trustee may deposit cash into the commercial or savings departments of any corporate fiduciary or of any other bank or Trust company or in any other depository. 7. Borrowing Monies. Trustee may borrow money for purposes it deems prudent and advisable, for the benefit of interested persons of this Trust estate, from any source including those which it may have personal interests in. 8. Asset Allocation of Principal and Income. Allocations between principal and income may be made, in Trustees discretion, of all receipts and disbursements, including receipts of estate assets received or accrued during estate administration, in any manner that will not result in the loss of any available estate tax deduction. Trustee may, but need not, create reserves out of income for depreciation, obsolescence, or amortization of properties. 9. Division of Assets for Distribution. Trustee may divide the Trust, to determine values, to distribute like or unlike assets to different beneficiaries or Trusts and to make distributions in cash or in kind, in divided or undivided interests; provided that any assets allocated in kind in satisfaction of any pecuniary gift shall be valued at fair market value of such asset on the date of such allocation and any assets which do not qualify for the federal marital deduction (or with respect to which a death tax is paid to a foreign country or subdivision thereof) shall be allocated to the Decedents Trust. 10. Direct Payments for Support. Trustee may make all payments of income of principal authorized hereunder directly to the beneficiary for the beneficiarys support, and, in the case of a beneficiary(s) who is(are) a minor or under other legal disability, all such payments (and any distributions of tangible personal property) may be made directly to the beneficiary(s). 11. Litigation Rights. Trustee may settle, compromise, submit to arbitration or litigate claims in favor of or against the Trust. 12. Ascertainment of Tax Deduction Elections. Trustee may contest, settle or compromise all tax matters, to elect to claim any expense of this Trust as an income tax deduction or as an estate tax deduction, and to make any other elections authorized or permitted by law all without reimbursement or adjustment between principal and income or in favor of any beneficiary, even if the elections directly affect the value of any beneficiarys share. COT Page 3 (of 5)PDF/59
  • 60. 13. Employment of Professional Assistance. Trustee may employ agents, lawyers, investment counsel, accountants etc. (even if they are associated with a Trustee), and to delegate ministerial and discretionary powers and duties to such persons with liability only for reasonable care in their selection, and to place assets in an account with a bank trust department they select, furnished by them without Independent investigations and to pay them reasonable compensation. 14. Latitude of Trustee Power. Trustee may exercise every other power (within the limits of discretion) not specifically granted by this agreement that may be necessary to enable it to create, continue, operate, expand or change forms of proprietorships, partnerships, joint ventures, corporations or other business in conjunction with this Trust including: (i) investing in any kind of property real or personal including interest of shares in common Trust funds, mutual funds or open end or closed end investment funds; (ii) to subdivide, resubdivide, raze, alter, vacate, partition, or release real estate and any or all improvements thereon to renew, amend, change, modify or extend leases, contract to make leases, grant options to lease, renew leases or to purchase the whole or any part of the reversion, to contract regarding the manner of fixing present or future rentals, and grant easements or changes of any kind on or with respect to such real estate; (iii) to continue to hold and invest in, or otherwise contract to acquire any right, title or interest, real or personal, in oil, gas or other mineral property, wheresoever located, whether or not productive, including all fractional or undivided rights for whatever term of interest, royalties payments, together with all options and privileges relating in any way to the exploring, drilling, mining, developing, completing, operating, improving and financing of oil, gas and other mineral property; and, (iv) to receive, retain indefinitely or invest in any interest in any holding company, family investment company, general or limited partnership, proprietorship, closely held corporation or other businesses; to rely upon the audited or unaudited reports of Certified Public Accountants as to the operations and financial conditions to any such business; to elect, employ and compensate regarding any such business and to delegate to others the power to perform such acts. 15. Exercise of Powers and Discretions. Trustee may freely exercise any of the powers and discretions granted to it in all matters concerning the Trust estate, after forming its judgment based upon all the circumstances of any particular situation as to the wisest and best course to pursue in the interest of the Trust and the beneficiaries, without the necessity of obtaining the consent or approval of any court. Trustee shall exercise such powers and discretions at all times in a fiduciary capacity primarily in the interests of the Trust beneficiaries. 16. Executing Instruments for Administration. Trustee may execute and deliver all instruments that will facilitate the exercise of the above powers/duties and to perform all other acts necessary or advisable to administer the Trust to any corporation, transfer agent, or governmental agency and to record a copy in the office of the County Recorder of any County. 17. Separate Shares Management As A Unit. Trustee need not make a physical segregation of assets when dividing the Trust into shares, but may allocate undivided interest in property to such shares by an accounting procedure or may allocate different properties thereto and may administer the assets of all shares as a unit until such time as Trustee is required to make distribution. In such event, separate accounts must be kept for each Trust estate and each share must be treated as a separate Trust for all purposes. 18. Risk Investments. Trustee may invest in options, futures or commodities and hold Trust securities in brokerage margin accounts if, in its discretion, such investments or holdings would seem prudent. Absent gross impropriety, Trustee shall not be held liable for any loss occurring as a result of such investments or holdings. COT Page 4 (of 5)PDF/60
  • 61. ARTICLE FOURTEEN - Non Liability of Separate Parties - Custodial agents, transfer agents, venders, financial institutions, physicians or any other "separate parties" (of this Trust) performing fiduciary or transferor duties or rendering any other service, pursuant to any such transfers, documents etc., for the furtherance of the purposes and intents of this Trust shall, absent of any fraud, be under no liability or obligations for the application or administration of this Trust, and shall not put the Trustee to task or inquiry regarding any supplements or amendments of this Trust, which may have been created and executed by the settlors from time to time, other than such supplements and amendments that the Trustee alone shall present to any separate party. ARTICLE FIFTEEN - Certificate of Trust Proving Existence- A Certificate of Trust signed by the Trustees of this Trust agreement and acknowledged before a Notary Public shall be conclusive evidence upon all persons and for all purposes of the facts stated in said Certificate respecting the terms of this Trust agreement and of the text thereof and of who are, from time to time, the Trustees hereunder. ACKNOWLEDGEMENT The Settlors/Trustees hereby execute this Certificate of Trust on this ______ day of ________________, 2012, by setting forth their signatures hereunto and as Trustees accept their appointment by signing, and thus certifying, this Certificate consisting of five (5) pages including this page. x____________________________________ x_______________________________ HENRY J. SMITH MARY A SMITH STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of _______________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) COT Page 5 (of 5) PDF/61
  • 62. SCHEDULES, LEDGERS & DEEDS Introduction This fifth section contains documents for property conveyance and characterization. Documents such as Quit Claim Deeds, Assignments of Beneficial Interest (e.g., Secured Realty Interest), Promissory Note conveyances, certain Limited Partnership interests, or whatever (other) transfer document(s) needed in your case, are all to be placed in this section. The Contemporaneous Property Agreement (enclosed) is designed to characterize the property you are funding to your trust which is determined by which Schedule (A, B, or C) such property is listed on. This is important for A/B tax planning reasons. The Assignment of Tangible/Personal Property (enclosed) is a useful tool in funding assets that typically do not have a title/certificate of ownership such as household furnishings, collectibles, clothing, heirlooms, coins, tools, guns, motor vehicles etc. Although you can retitle your motor vehicle to your trust, this document has always worked very well in transferring motor vehicles into a living trust. The Schedules - A, B, C (mentioned above) & D - should be filled in. Trust law has determined that listing assets on a Schedule (only) is another way of funding the trust. Although we agree with this, we still recommend retitling all assets whenever possible. Nevertheless, you should list all assets (not conveyed by the Personal Property Assignment) in the proper Schedules provided in this section. The Settlors Chattel Schedule is a form that allows you to list names of individuals whom you wish to receive a certain personal property item of yours. Just list such item, on that Schedule, and the name of the person (beneficiary) who is to receive that item. The trust instructs the trustee to distribute such item to the named individual. Both spouses need to sign certain documents now. Some documents are to be filled in and/or signed later. Please refer to the previous Portfolio Summary Section if additional clarification is needed. _______________PDF/62
  • 63. CONTEMPORANEOUS PROPERTY AGREEMENT This contemporaneous declaration & agreement is made herein between the undersigned, HENRY J. SMITH & MARY A SMITH, a married couple, for the primary purpose of transmuting certain of their property into Community Property, equally owned. WHEREAS any and all property held in any form of co-ownership between the Settlor/Spouses which is to be and shall be transferred, by a proper and binding conveyance instrument, to the Trustee(s) of that certain Declaration of Trust Agreement known as the SMITH FAMILY TRUST to wit: HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 is hereby declared, by each Spouse, to be Community Property. WHEREAS any and all sole and separate property of either Spouse which is to be and shall be transferred, by a proper and binding conveyance instrument into said trust is hereby declared and agreed by the Spouses to be Community Property of said Spouses as listed on the Community Property Schedule. NOTWITHSTANDING, any property listed on a respective Separate Property Schedule(s) of either Settlor/Spouse, in said Trust, shall be deemed to be Sole and Separate Property of a respective Settlor/Spouse regardless of the original characterization of such listed property prior to its transfer to said Trust. ANY property not transferred into said Trust agreement shall retain its character of ownership and shall not be transmuted or be under the provisions of this declaration and agreement. x________________________________ x________________________________ HENRY J. SMITH MARY A SMITH ACKNOWLEDGEMENT STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of _______________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) PDF/63
  • 64. ASSIGNMENT OF PERSONAL PROPERTY We, HENRY J. SMITH & MARY A SMITH, the undersigned, the Settlors of that certain Declaration of Trust & Agreement referred to below, hereby assign all of our rights, title and interest in and to all of our personal property, including, but not limited to, all of our personal and household effects, jewelry, books, pictures, works of art, furniture, antiques, collections, coins, precious metals, gems, livestock, all sporting and other equipment, tools of any kind, all motor vehicles, and all contents of our safe deposit box(es) to: HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 and to our successor trustee(s) thereafter and declare that such assignment shall be distributed according to the dispositive provisions set forth in said Trust. We further declare that we are acquiring and will hold in the name of said Trust all items listed on the Property Schedule(s) attached hereto and incorporated herein as amended from time to time and including, but not limited to, all assets that may have been inadvertently omitted from the Property Schedule(s) or acquired subsequent to the execution of the Trust, whether listed or hereinafter acquired, and henceforth declare that such assets shall and will belong to said Trust and not to us as individuals. x________________________________ x________________________________ HENRY J. SMITH MARY A SMITH ACKNOWLEDGEMENT STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, ____________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) PDF/64
  • 65. SCHEDULE  “A” SMITH FAMILY TRUST (Community Property) ______________________________________________ Asset Date Trustee(s) Identification Funded Initials _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____PDF/65
  • 66. SCHEDULE  “A” SMITH FAMILY TRUST (Community Property) ______________________________________________ Asset Date Trustee(s) Identification Funded Initials _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____PDF/66
  • 67. SCHEDULE  “B” SMITH FAMILY TRUST (Spouses Separate Property) ______________________________________________ Asset Date Trustee(s) Identification Funded Initials _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____PDF/67
  • 68. SCHEDULE  “C” SMITH FAMILY TRUST (Spouses Separate Property) ______________________________________________ Asset Date Trustee(s) Identification Funded Initials _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____ _________________________________________ ____________ _____ /_____PDF/68
  • 69. SCHEDULE  “D” - DEATH BENEFITS PAYABLE TO TRUST - (Life Insurance, Annuities, IRAs, Pension Plans etc.) ______________________________________________ Benefit Description/Account No. Issuing Entity __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ NOTE: List the beneficiary designation of each above listed "Death Benefit" assets whether the trust is the "Primary Beneficiary" (P) or the "Contingent Beneficiary" (C).PDF/69
  • 70. PERSONAL PROPERTY SCHEDULE (For Itemized Distributions) HENRY J. SMITH HENRY J. SMITH, a Settlor of the SMITH FAMILY TRUST, hereby delivers to the trustees of this trust all of his tangible personal property which he holds in this trust recorded and identified below which is to be distributed to the persons described below respective of each separate item. x________________________________ HENRY J. SMITH Property Item Recipient ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________PDF/70
  • 71. PERSONAL PROPERTY SCHEDULE (For Itemized Distributions) MARY A SMITH MARY A SMITH, a Settlor of the SMITH FAMILY TRUST, hereby delivers to the trustees of this trust all of her tangible personal property which she holds in this trust recorded and identified below which is to be distributed to the persons described below respective of each separate item. x________________________________ MARY A SMITH Property Item Recipient ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________ ____________________________________ ________________________________PDF/71
  • 72. SUB-TRUST  “A”  /  ASSET ACCOUNTING LEDGER (SURVIVORS ESTATE) Listed below are the assets, or portions thereof, designated as property of the Survivors Trust (Trust "A"), a sub-trust of the: SMITH FAMILY TRUST Dated: ______________________, 2012 created under the powers and provisions of said Trust and funded after the death of the first Settlor/Spouse to die. Asset Description/Account No. Portion/Percentage of Asset ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ x________________________________ TrusteePDF/72
  • 73. SUB-TRUST  “B”  /  ASSET  ACCOUNTING  LEDGER (DECEDENTS ESTATE) Listed below are the assets, or portions thereof, designated as property of the Decedents Trust (Trust "B"), a sub-trust of the: SMITH FAMILY TRUST Dated: ______________________, 2012 created under the powers and provisions of said Trust and funded after the death of the first Settlor/Spouse to die. Asset Description/Account No. Portion/Percentage of Asset ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ x________________________________ TrusteePDF/73
  • 74. SUB-TRUST  “C”  /  ASSET  ACCOUNTING  LEDGER (QUALIFIED TERMINABLE INTEREST PROPERTY) Listed below are the assets, or portions thereof, designated as property of the Qualified Terminable Interest Property Trust (Trust "C"), a sub-trust of the: SMITH FAMILY TRUST Dated: ______________________, 2012 created under the powers and provisions of said Trust and funded, as elected by the Trustee, after the death of the first Settlor/Spouse to die. Asset Description/Account No. Portion/Percentage of Asset ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ ____________________________________________ ___________________ x________________________________ TrusteePDF/74
  • 75. LOCATER REFERENCE LEDGER SMITH FAMILY TRUST Listed below are addresses and phone numbers of individuals who are appointed as successor trustees (of trust), personal representatives (of will), agents for powers of attorney and other administrative co-agents and/or beneficiaries of the trust estate. Individual Address/Phone _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________PDF/75
  • 76. LOCATER REFERENCE LEDGER SMITH FAMILY TRUST Listed below are addresses and phone numbers of individuals who are appointed as successor trustees (of trust), personal representatives (of will), agents for powers of attorney and other administrative co-agents and/or beneficiaries of the trust estate. Individual Address/Phone _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________ _________________________________ _________________________________ (Name) _________________________________ _________________________________PDF/76
  • 77. ADMINISTRATIVE DOCUMENTS Introduction This sixth section contains most of the administrative documents of your estate plan which primarily pertain to your trust. These documents/forms are designed for ease of administration for you now, as trustee, and convenience for your successor trustee (and attending physician) to use as needed in the future. It would be wise to first make copies of any document that you are going to use and keep the originals in your Portfolio. The reason is - if you use copies of these documents rather than the originals, you will always have an original to copy (and use) later if and when needed. These documents have been carefully thought out and constructed for your convenience. They will save you money. Their proper use should preclude the need to pay extra fees to have additional documents drafted to address estate- planning changes and situations that may (and will) arise, in the future. The administration documents are designed and written to be self explanatory as well as useful. However, if you have any questions about any of the forms, or the use of them, refer to the Portfolio Summary Section (first section) of your Estate Planning Portfolio. In the Portfolio Summary Section you will find definitions of each document in this section. These documents do not necessarily need to be signed to implement your Estate Plan. They are generally to be signed (and notarized) at a later time when needed. Please refer to the Portfolio Summary Section for clarification. _______________PDF/77
  • 78. APPOINTMENT OF NOMINEE TRUSTEE BE IT KNOWN THAT WE, HENRY J. SMITH & MARY A SMITH, the undersigned, declare that we are the Settlors of that certain (revocable) Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 and that we have elected – by the authority stated under Article Ten of said Trust – to appoint another as a Nominee Trustee to serve as our Agent in the office of Trustee of said Trust which we are now currently serving. THEREFORE, pursuant to such authority and right, __________________________ is hereby authorized by us TO ACT ALONE in signing all transactions, entering into all buying and selling contracts or carrying out any other fiduciary duties and powers pertaining to this Trust as it applies to the powers and requirements bestowed upon the Trustee of this Trust. _______________________________ shall now herewith be authorized, by us, to act alone as though he/she were the sole Trustee of this Trust – until further (written) notice is expressly given to the contrary. No further inquiry is required by any third party to this Trust to substantiate or verify the authenticity and meaning of this appointment. x__________________________________ x________________________________ HENRY J. SMITH MARY A SMITH - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, _____, before me, ________________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of __________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/78
  • 79. TRUST  “B”  APPORTIONMENT  AMENDMENT We, HENRY J. SMITH & MARY A SMITH, the undersigned, declare that we are the Settlors of that certain (revocable) Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 and that we have elected, within compliance to applicable provisions of said Trust, to amend said Trust, as follows: WHEREAS, under Article One, the Settlors reserve the right of revocation and amendment (within Trust provisions) to any and all Articles to said Trust. THEREFORE, pursuant to such authority and right, the undersigned hereby declare that – notwithstanding the non-apportionment provision in said Trust – said Trust shall be divided into Trust "A" and Trust "B" upon the death of the first Settlor to die. This shall mean that the Trust   estate   of   the   first   Settlor   to   die   shall   be   transferred   to   Trust   "B"   (and   Trust   “C”,   as   necessary); the Trust estate of the surviving Settlor shall be transferred to Trust "A". ACCORDINGLY, this Amendment shall apply notwithstanding that there may be no transfer tax avoidance purpose to create such apportionment. This Amendment No. ____________ of said Trust is hereby executed and to be effective on this the _____ day of __________________, _______. x_________________________________ x_________________________________ HENRY J. SMITH MARY A SMITH STATE OF ______________________ COUNTY OF ____________________ On this ______ day of _______________, _____, before me, ________________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/79
  • 80. TRUST  “B”  FIVE  &  FIVE  AMENDMENT We, HENRY J. SMITH & MARY A SMITH, the undersigned, declare that we are the Settlors of that certain (revocable) Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 and that we have elected, within compliance to applicable provisions of said Trust, to amend said Trust, as follows: WHEREAS, under Article One, the Settlors reserve the right of revocation and amendment (within Trust provisions) to any and all Articles to said Trust. THEREFORE, pursuant to such authority and right, the undersigned hereby declare that the surviving Settlor/Spouse shall have the authority and right to withdraw from the Credit Shelter Trust "B" (aka - the Decedents Trust), an amount not to exceed five thousand dollars ($5,000) or five percent (5%) of the principal of Trust "B" (the Decedents Trust), whichever is greater, but only on an annual and non-accumulative basis. ACCORDINGLY, this Amendment shall apply notwithstanding any other income or principal distributions available, as per said Trust, for the benefit of the surviving spouse from Trust "B" of said Trust. This Amendment No. ____________ of said Trust is hereby executed and to be effective on this the _____ day of __________________, _______. x_________________________________ x_________________________________ HENRY J. SMITH MARY A SMITH STATE OF ______________________ COUNTY OF ____________________ On this ______ day of _______________, _____, before me, ________________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/80
  • 81. TRUST  “B”  REMARRIAGE FORFEITURE AMENDMENT We, HENRY J. SMITH & MARY A SMITH, the undersigned, declare that we are the Settlors of that certain (revocable) Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 and that we have elected, within compliance to applicable provisions of said Trust, to amend said Trust, as follows: WHEREAS, under Article One, the Settlors reserve the right of revocation and amendment (within Trust provisions) to any and all Articles to said Trust. THEREFORE, pursuant to such authority and right, the undersigned hereby declare that in the event that the surviving Settlor/Spouse remarries (after the death of the first Settlor to die) then Trust "B" (Decedents Trust) shall be administrated and distributed for and to the benefit of the heirs of the first Settlor to die as though the surviving Settlor had then died - effective on the date of his/her remarriage. ACCORDINGLY, this Amendment shall apply notwithstanding any other income or principal distributions previously available, as per said Trust, to the surviving spouse from Trust "B" of said Trust. This Amendment No. ____________ of said Trust is hereby executed and to be effective on this the _____ day of __________________, _______. x_________________________________ x_________________________________ HENRY J. SMITH MARY A SMITH STATE OF ______________________ COUNTY OF ____________________ On this ______ day of _______________, _____, before me, ________________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/81
  • 82. RELINQUISHMENT OF CO-TRUSTEE DUTY HENRY J. SMITH I, HENRY J. SMITH, the undersigned, hereby declare that I am a Settlor and a Co-Trustee of and under that certain Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 in which provision is made for a Settlors voluntary release of authority as Trustee to the other Co-Trustee named therein. I, the undersigned Settlor/Co-Trustee under said Trust Agreement, by this statement, voluntarily relinquish all authority, power, right and duty as Co-Trustee to my spouse, MARY A SMITH, who shall act alone as Trustee and shall have and exercise all of the powers vested in Trustee as authorized in said Trust. x________________________________ HENRY J. SMITH - ACKNOWLEDGEMENT - STATE OF _____________________ COUNTY OF ___________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/82
  • 83. RELINQUISHMENT OF CO-TRUSTEE DUTY MARY A SMITH I, MARY A SMITH, the undersigned, hereby declare that I am a Settlor and a Co-Trustee of and under that certain Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 in which provision is made for a Settlors voluntary release of authority as Trustee to the other Co-Trustee named therein. I, the undersigned Settlor/Co-Trustee under said Trust Agreement, by this statement, voluntarily relinquish all authority, power, right and duty as Co-Trustee to my spouse, HENRY J. SMITH, who shall act alone as Trustee and shall have and exercise all of the powers vested in Trustee as authorized in said Trust. x________________________________ MARY A SMITH - ACKNOWLEDGEMENT - STATE OF ____________________ COUNTY OF __________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/83
  • 84. REINSTATEMENT AS CO-TRUSTEE HENRY J. SMITH I, HENRY J. SMITH, the undersigned, hereby declare that I am a Settlor and was a Co- Trustee of and under that certain Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 in which provision is made for a Spouse/Settlors voluntary release of authority as Trustee/Co- Trustee as well as for his appointment and restatement as Trustee/Co-Trustee, by himself, for and to said Trust Agreement. THEREFORE, I, the undersigned Spouse/Settlor under said Trust Agreement, by this statement, hereby appoint and reinstate myself as Co-Trustee with my spouse and declare that I shall have and exercise all of the powers vested in Trustee as authorized in said Trust. x________________________________ HENRY J. SMITH - ACKNOWLEDGEMENT - STATE OF _____________________ COUNTY OF ___________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/84
  • 85. REINSTATEMENT AS CO-TRUSTEE MARY A SMITH I, MARY A SMITH, the undersigned, declare that I am a Settlor and was a Co-Trustee of and under that certain Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 in which provision is made for Spouse/Settlors voluntary release of authority as Trustee/Co- Trustee as well as for her appointment and restatement as Trustee/Co-Trustee, by herself, for and to said Trust Agreement. THEREFORE, I, the undersigned Spouse/Settlor under said Trust Agreement, by this statement, hereby appoint and reinstate myself as Co-Trustee with my spouse and declare that I shall have and exercise all of the powers vested in Trustee as authorized in said Trust. x________________________________ MARY A SMITH - ACKNOWLEDGEMENT - STATE OF _____________________ COUNTY OF ___________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/85
  • 86. (CO-)SETTLOR’S  RELINQUISHMENT TO SUCCESSOR TRUSTEE I, HENRY J. SMITH, the undersigned, declare that I am the Settlor/Trustee under that certain Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 in which provision is made for the Settlors voluntary release of authority as Trustee(s) to the Successor Trustee, named therein. Therefore, by this statement, I voluntarily relinquish all authorities, powers and rights as Trustee, under said Trust agreement, to the Successor Trustee – HENRY J SMITH, JR who shall, hereafter, have and exercise all of the powers vested in Trustee as authorized in said Trust. x________________________________ HENRY J. SMITH - ACKNOWLEDGEMENT - STATE OF _____________________ COUNTY OF ___________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/86
  • 87. (CO-)SETTLOR’S  RELINQUISHMENT TO SUCCESSOR TRUSTEE I, MARY A SMITH, the undersigned, declare that I am the Settlor/Trustee under that certain Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 in which provision is made for the Settlors voluntary release of authority as Trustee(s) to the Successor Trustee, named therein. Therefore, by this statement, I voluntarily relinquish all authorities, powers and rights as Trustee, under said Trust agreement, to the Successor Trustee - HENRY J SMITH, JR who shall, hereafter, have and exercise all of the powers vested in Trustee as authorized in said Trust. x________________________________ MARY A SMITH - ACKNOWLEDGEMENT - STATE OF ______________________ COUNTY OF ____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/87
  • 88. SUCCESSOR TRUSTEES NOTICE PLEASE TAKE NOTICE THAT I, the undersigned - HENRY J SMITH, JR named as Successor Trustee under that certain Declaration of Trust Agreement referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 of which a copy of an abstract of such Trust (Certificate of Trust) is appended hereto and made a part hereof, hereby give notice that I have assumed the duties of (Successor) Trustee as stated therewith in said Trust agreement. ADDITIONALLY, and in support thereof, a copy of one of the documents listed below (identified by checkmark) is attached hereto, in accordance with said Trust agreement, and made a part hereof (check one): _____ SETTLOR RELINQUISHMENT OF TRUSTEESHIP _____ MEDICAL CERTIFICATION (PHYSICIANS NOTICE) _____ DEATH CERTIFICATE OF SETTLOR(S) THEREFORE I, HENRY J SMITH, JR, as Successor Trustee, shall assume full rights, title and interest in and to personal and real property comprising the assets of said Trust and declare that such conveyance of property has been accepted by me this date and shall be administrated according to provisions of said Trust. x________________________________ HENRY J SMITH, JR - ACKNOWLEDGEMENT - STATE OF ______________________ COUNTY OF ____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared HENRY J SMITH, JR who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of __________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/88
  • 89. SUCCESSOR TRUSTEES DECLINATION TO WHOM IT CONCERNS: I, HENRY J SMITH, JR, the undersigned, appointed as a Successor Trustee of that certain Declaration of Trust Agreement referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 do hereby declare that I revoke, refuse and decline forever my appointment as Successor Trustee of said Trust Agreement. IN THE EVENT the alternate Successor Trustee, if any, is unwilling or unable to serve and/or no additional "alternate" had been appointed, then the following provision described below shall be in effect (and according to such provision) as stated in said Trust agreement: (check one) _____ The declining/vacating Successor Trustee may appoint a successor to occupy such vacancy. _____ A majority vote of the surviving beneficiaries of said Trust agreement shall elect and appoint a Successor Trustee. _____ A court-appointed individual or corporate entity shall serve as the Successor Trustee. x________________________________ HENRY J SMITH, JR - ACKNOWLEDGEMENT - STATE OF ______________________ COUNTY OF ____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared HENRY J SMITH, JR who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/89
  • 90. SUCCESSOR TRUSTEES TERMINATION I (WE), _______________________________________________, the undersigned, declare that I (we) am (are) the Settlor(s) under that certain (revocable) Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 and, being of sound mind and fully capable of prudent decisions, have elected to terminate any and all authority granted to - HENRY J SMITH, JR elected to serve as Successor Trustee in accordance with the conditions described in said Trust agreement as evidenced by the SUCCESSOR TRUSTEES NOTICE document dated on the _____ day of _____________, ______. WHEREFORE, I (WE), the undersigned Settlor(s) give notice that all of the authorities, powers and rights accorded to such Successor Trustee under said Trust agreement on _____________________________, ________ (date of Successor Trustees Notice), are hereby terminated this day; and therefore, all rights title and interest in and to any and all of the Trust assets are hereby conveyed and assigned back to me (us) as Trustee(s) of said Trust Agreement. Dated this _____ day of __________________, _______. x___________________________________ x_______________________________ HENRY J. SMITH MARY A SMITH - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/90
  • 91. AMENDMENT TRUSTEE APPOINTMENT CHANGE We (I), _____________________________________________, the undersigned, declare that we (I) are (am) the Settlor(s) of that certain (revocable) Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 and that we (I) have elected, within compliance to applicable provisions of said Trust, to amend said Trust, by those presents, to wit: WHEREAS, under Article One, the Settlors reserve the right of revocation and amendment (within Trust provisions) to any and all Articles to said Trust including the right to revocation of Trustee appointment(s). THEREFORE, pursuant to such authority and right, the undersigned hereby rescind and revoke the appointment of - ______________________________ as Successor Trustee(s) of said Trust and appoint as his/her/their substitution - ______________________________ to serve as Successor Trustee(s) in lieu of such prior appointment. This Amendment No. ____________ of said Trust is hereby executed and to be effective on this the _____ day of __________________, _______. x________________________________ x________________________________ HENRY J. SMITH MARY A SMITH - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/91
  • 92. AMENDMENT DISTRIBUTION OF TRUST ASSETS We (I), _____________________________________________, the undersigned, declare that we (I) are (am) the Settlor(s) of that certain (revocable) Declaration of Trust Agreement referred to and known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 and that we (I) have elected, within compliance to applicable provisions of said Trust, to amend said Trust, by those presents, to wit: WHEREAS, under Article One, the Settlors reserve the right of revocation and amendment (subject to Trust powers) to any and all Articles to said Trust including the right to amend or revoke provisions for distributions of property. THEREFORE, pursuant to such authority and right, the undersigned hereby amend the language concerning distribution of assets under Article ___________, Paragraph ______ to instead read, state and provide as follows: (NOTE: Unless expressly allowed, a surviving Settlor/Spouse may not amend or alter distributions or provisions concerning the decedent Spouses assets funded to a Credit Shelter or QTIP Trust) _____________________________________________________________ _____________________________________________________________ This Amendment No. ____________ of said Trust is hereby executed and to be effective on this the _____ day of __________________, _______. x________________________________ x________________________________ HENRY J. SMITH MARY A SMITH - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH & MARY A SMITH, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/92
  • 93. DISCLAIMER SURVIVING  SETTLORS  DISCLAIMER  OF  TRUST  “B”  INCOME I, _________________________________, the undersigned, declare that I am the surviving Settlor of that certain Declaration of Trust Agreement known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 As concerning Article Six of said Trust, I, by this expressed statement, hereby relinquish and disclaim forever any and all rights, interest and beneficial enjoyment to all - INCOME DISTRIBUTIONS of and from my decedent spouses Credit Shelter Trust Estate (Trust "B") established for me under Article Four of said Trust. If the right to receive such income distributions is the only beneficial enjoyment that I currently am entitled to receive from Trust "B", as of this date, then such Trust "B" shall be administrated and distributed as though I had then deceased on this date. Provided that I have executed this disclaimer within the time requirements of State statutes and the Internal Revenue Code (Section 2518) and provided I have not accepted any such benefits of Trust "B", I declare this disclaimer to be qualified herein where this disclaimer shall not be deemed a gift for transfer tax purposes. If I have not executed this disclaimer within the time requirements and/or have accepted benefits of Trust "B", that would otherwise create a non-qualified transfer (non- qualified for tax purposes), I declare this disclaimer to be a gift, for transfer tax purposes, to the persons receiving benefits of this disclaimer as provided herein. x________________________________ Surviving Settlor - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared _________________________________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/93
  • 94. DISCLAIMER SURVIVING  SETTLORS  DISCLAIMER  OF  TRUST  “B”  PRINCIPAL I, _________________________________, the undersigned, declare that I am the surviving Settlor of that certain Declaration of Trust Agreement known as the: SMITH FAMILY TRUST Dated: ______________________, 2012 As concerning Article Six of said Trust, I, by this expressed statement, hereby relinquish, and disclaim forever any and all powers, rights, interest and beneficial enjoyment to all - GRANTS TO/FOR INVASION OF PRINCIPAL of and from my decedent spouses Credit Shelter Trust Estate (Trust "B") established for me under Article Five of said Trust. If the right to receive distributions from principal is the only beneficial enjoyment that I currently am entitled to receive from Trust "B", as of this date, then Trust "B" shall be administrated and distributed as though I had then deceased on this date. If I have executed this disclaimer within the time requirements of State statutes and the Internal Revenue Code (Section 2518) and provided I have not accepted any such benefits of Trust "B", I declare this disclaimer to be qualified herein where this disclaimer shall not be deemed a gift for transfer tax purposes. If I have not executed this disclaimer within the State and Federal time requirements and/or have accepted benefits of Trust "B", that would otherwise create a non- qualified transfer (non-qualified for tax purposes), I declare this disclaimer to be a gift, for transfer tax purposes, to the persons receiving benefits of this disclaimer as provided herein. x________________________________ Surviving Settlor - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared _________________________________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/94
  • 95. PHYSICIAN MEDICAL CERTIFICATION for HENRY J. SMITH Attending Physician: ____________________________________________ Practice Address: ____________________________________________ Date of Certification: ____________________________________________ TO WHOM IT CONCERNS: I, ________________________________, the attending physician of HENRY J. SMITH who presents himself to be a (the) Settlor/Trustee of the SMITH FAMILY TRUST, have diagnosed his medical/mental condition as follows: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ I declare therefore, by this Certification in writing, that, in my professional opinion, HENRY J. SMITH has a present medical/mental condition that would significantly impair his normal ability to act as a fiduciary, in any capacity, concerning his own affairs and expressly that as of a trustee or as an attorney-in-fact for another. Further, I disavow any liability or responsibility as to the intended application or use of this Certification. x________________________________ Attending Physician - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared the above identified attending physician who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/95
  • 96. PHYSICIAN MEDICAL CERTIFICATION for MARY A SMITH Attending Physician: ____________________________________________ Practice Address: ____________________________________________ Date of Certification: ____________________________________________ TO WHOM IT CONCERNS: I, ________________________________, the attending physician of MARY A SMITH who presents herself to be a (the) Settlor/Trustee of the SMITH FAMILY TRUST, have diagnosed her medical/mental condition as follows: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ I declare therefore, by this Certification in writing, that, in my professional opinion, MARY A SMITH has a present medical/mental condition that would significantly impair her normal ability to act as a fiduciary, in any capacity, concerning her own affairs and expressly that as of a trustee or as an attorney-in-fact for another. Further, I disavow any liability or responsibility as to the intended application or use of this Certification. x________________________________ Attending Physician - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ______, before me, _____________________, the undersigned, personally appeared the above identified attending physician who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/96
  • 97. DURABLE POWERS OF ATTORNEY Introduction This seventh section contains two separate Powers of Attorney. One Power of Attorney pertains to financial matters; the other applies to health care. In both documents, the word "durable" is used to describe the power. This simply means that the appointment of the power (to your agent) would "endure" past your incapacitation; i.e., it would still be valid even if you were unable to function, either physically or mentally, on your own. The Durable Power of Attorney Over Assets document will give your appointed agent the power to make basic financial decisions. Examples are to - buy and sell, write checks from your accounts etc. This power is effective either upon the date of execution of the document or upon your incapacitation (you have made the choice in the Questionnaire and it is stated in the document). Realize, however, that your agent will have power over only those assets that have not been funded into your trust. If you wish to leave a small bank account out of your trust and you later become incapacitated, then your agent can transact for you out of such bank account. More importantly, if certain assets have been left unfunded, at the time of your incapacitation, then your agent can transfer such assets to your trust. This would allow your trust to control such assets and probate (of those assets) would be avoided. The Durable Power of Attorney for Health Care (DPAHC) document allows your appointed agent to make important health care decisions for you in lieu of your own decisions, in the event of your incapacitation. In fact, the most significant power of the DPAHC is that the agent can terminate life support systems for the principal (the person granting the power) even if the principal is not "terminally" ill. Both documents (two for each spouse) must be signed and notarized. _______________PDF/97
  • 98. NOTICE: THE POWERS GRANTED TO THE AGENT YOU ARE APPOINTING HEREIN CAN BE VERY BROAD. CONSULTATION WITH A LEGAL ADVISOR IS RECOMMENDED. THIS DOCUMENT DOES NOT AUTHORIZE THE AGENT NAMED WITHIN TO MAKE MEDICAL OR OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY AT ANY TIME. DURABLE POWER OF ATTORNEY – OVER ASSETS – This Power of Attorney authorizes the person named below as my Attorney-in-Fact to sell, lease, grant, encumber, release or otherwise convey any interest in my real property, execute deeds and all other such instruments on my behalf unless I have otherwise limited such power herein to specific real property or otherwise withheld such power regarding all real estate transactions as defined below. I, HENRY J. SMITH, the undersigned, have appointed MARY A SMITH, my spouse, to serve as my lawful Attorney-in-Fact over assets – or if my spouse is unwilling or unable to serve then I appoint HENRY J SMITH, JR (as my first alternate) or ANN B SMITH (as my second alternate) – to perform for me and in my name certain acts which I might and could do if I were present and capable by granting herewith the following INITIALED powers: NOTICE: TO GRANT ALL OF THE FOLLOWING POWERS TO YOUR ATTORNEY-IN-FACT, INITIAL THE LINE IN FRONT OF - (O) - AND IGNORE THE LINES IN FRONT OF ALL THE OTHER LISTED POWERS. NOTICE: TO GRANT ONE OR MORE, BUT FEWER THAN ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING TO YOUR ATTORNEY-IN-FACT. NOTICE: TO WITHHOLD A FOLLOWING POWER(S), DO NOT INITIAL THE LINE ADJACENT TO SUCH POWER. YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER TO BE WITHHELD. AUTHORIZATION BY INITIALS OF UNDERSIGNED PRINCIPAL: _______ (A) To engage in banking and/or other financial institution transactions viz: executing, endorsing, collecting, depositing and receiving checks against or in my bank (or other) accounts, including checks drawn on the Treasurer of the United States. _______ (B) To buy, sell and/or otherwise transfer and/or gift my real estate property or engage in any related real property transactions. _______ (C) to buy, sell and/or otherwise transfer and/or gift my tangible personal property or engage in any related personal property transactions. DPA/Asset Page 1 (of 4)PDF/98
  • 99. _______ (D) To buy, sell and/or otherwise transfer and/or gift my cash, cash equivalents or other equitable items. _______ (E) To engage in stock and/or bond (including stock or bond powers) transactions. _______ (F) To engage in commodities and/or options transactions. _______ (G) To engage in operational business transactions. _______ (H) To engage in insurance and/or annuity transactions. _______ (I) To engage in personal claims and/or litigation transactions. _______ (J) To engage in personal and/or family maintenance transactions. _______ (K) To receive benefits from social security, Medicare, Medicaid, or other governmental programs, including military service related benefits. _______ (L) To receive or otherwise handle retirement plan(s) transactions. _______ (M) To enter in to my safe deposit box and remove the contents thereof. _______ (N) To handle personal (or related) tax matters. _______ (O) ALL OF THE POWERS LISTED ABOVE. _______ (P) TO RECEIVE REASONABLE FEES/REIMBURSEMENT FOR COSTS & EXPENSES INCURRED AS AN AGENT ACTING HEREUNDER. NOTICE: IF THIS DOCUMENT HAS BEEN ELECTRONICALLY VERIFIED ("ESIGNd") THEN ALL OF THE ABOVE ITEMS (A-P) SHALL BE DEEMED AS AFFIRMATIVELY CHECKED/INITIALED. 1. Additionally, I give power to my Attorney-in-Fact to assign, transfer, convey and deliver to the Trustee of that certain Declaration of Trust referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 any and all of my property such as cash, stocks, bonds, securities, annuities and any other property of any kind whether real property or personal; to endorse and deliver to said trustee(s) any checks, drafts, certificates of deposit, notes receivable or other instruments for which I have an interest in as monies payable or belonging to me; to designate the Trustee, of said Trust, as the beneficiary any life insurance policies, employee benefit or pension plans or individual retirement accounts owned by me or in which I have an interest, and, in general, to do all things which I, as a grantor of a living trust, might do if present and capable. DPA/Asset Page 2 (of 4)PDF/99 
  • 100. 2. Notwithstanding the above provisions, my Attorney-in-Fact shall have NO power to transact with any assets/properties which have been transferred to said Trust either by me or by my Attorney-in-Fact unless the Trustee of said Trust expressly grants to my Attorney-in-Fact the right to act as a nominee Trustee or agent over any specific asset(s) held in said Trust. 3. Unless otherwise provided hereunder, this Power of Attorney shall spring into effect upon the execution of an opinion letter or medical certification of my attending physician (delivered to my Attorney-in-Fact) certifying my incapacity to carry on my normal fiduciary affairs because of a mental or physical impairment and shall continue therein until a certification from a licensed physician declares that the impairment is no longer effective or applicable. This Power of Attorney shall not be affected by the subsequent disability or incompetence of the principal. Notwithstanding the terms of this paragraph, to the extent this Power of Attorney is intended to be exercised in a jurisdiction not then currently recognizing its efficacy at a "future date" – based upon the occurrence of a future event or contingency – then this Power of Attorney shall be deemed as being effective immediately as to its application in any such jurisdiction. ___________________ I understand the full importance of this Durable Power Of Attorney Over Assets document and I have emotional and mental capacity to execute such document. x________________________________ HENRY J. SMITH ACKNOWLEDGEMENT The Declarant signing this foregoing Power of Attorney for Over Assets is personally known to us or has provided proof of his identity, signed or acknowledged his signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as his health care representative, has not named either of us as a beneficiary of his estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address DPA/Asset Page 3 (of 4) PDF/100
  • 101. STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within Durable Power of Attorney Over Assets instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) DPA/Asset Page 4 (of 4)PDF/101 
  • 102. NOTICE: THE POWERS GRANTED TO THE AGENT YOU ARE APPOINTING HEREIN CAN BE VERY BROAD. CONSULTATION WITH A LEGAL ADVISOR IS RECOMMENDED. THIS DOCUMENT DOES NOT AUTHORIZE THE AGENT NAMED WITHIN TO MAKE MEDICAL OR OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY AT ANY TIME. DURABLE POWER OF ATTORNEY ~ OVER ASSETS ~ This Power of Attorney authorizes the person named below as my Attorney-in- Fact to sell, lease, grant, encumber, release or otherwise convey any interest in my real property, execute deeds and all other such instruments on my behalf unless I have otherwise limited such power herein to specific real property or withheld such power regarding all real estate transactions as defined below. I, MARY A SMITH, the undersigned, have appointed HENRY J. SMITH, my spouse, to serve as my lawful Attorney-in-Fact over assets – or if my spouse is unwilling or unable to serve then I appoint HENRY J SMITH, JR (as my first alternate) or ANN B SMITH (as my second alternate) – to perform for me and in my name certain acts which I might and could do if I were present and capable by granting herewith the following INITIALED powers: NOTICE: TO GRANT ALL OF THE FOLLOWING POWERS TO YOUR ATTORNEY-IN-FACT, INITIAL THE LINE IN FRONT OF - (O) - AND IGNORE THE LINES IN FRONT OF ALL THE OTHER LISTED POWERS. NOTICE: TO GRANT ONE OR MORE, BUT FEWER THAN ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING TO YOUR ATTORNEY-IN-FACT. NOTICE: TO WITHHOLD A FOLLOWING POWER(S), DO NOT INITIAL THE LINE ADJACENT TO SUCH POWER. YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER TO BE WITHHELD. AUTHORIZATION BY INITIALS OF UNDERSIGNED PRINCIPAL: _______ (A) To engage in banking and/or other financial institution transactions viz: executing, endorsing, collecting, depositing and receiving checks against or in my bank (or other) accounts, including checks drawn on the Treasurer of the United States. _______ (B) To buy, sell and/or otherwise transfer and/or gift my real estate property or engage in any related real property transactions. _______ (C) to buy, sell and/or otherwise transfer and/or gift my tangible personal property or engage in any related personal property transactions. DPA/Asset Page 1 (of 4)PDF/102
  • 103. _______ (D) To buy, sell and/or otherwise transfer and/or gift my cash, cash equivalents or other equitable items. _______ (E) To engage in stock and/or bond (including stock or bond powers) transactions. _______ (F) To engage in commodities and/or options transactions. _______ (G) To engage in operational business transactions. _______ (H) To engage in insurance and/or annuity transactions. _______ (I) To engage in personal claims and/or litigation transactions. _______ (J) To engage in personal and/or family maintenance transactions. _______ (K) To receive benefits from social security, Medicare, Medicaid, or other governmental programs, including military service related benefits. _______ (L) To receive or otherwise handle retirement plan(s) transactions. _______ (M) To enter in to my safe deposit box and remove the contents thereof. _______ (N) To handle personal (or related) tax matters. _______ (O) ALL OF THE POWERS LISTED ABOVE. _______ (P) TO RECEIVE REASONABLE FEES/REIMBURSEMENT FOR COSTS & EXPENSES INCURRED AS AN AGENT ACTING HEREUNDER. NOTICE: IF THIS DOCUMENT HAS BEEN ELECTRONICALLY VERIFIED ("ESIGN/ED") THEN ALL OF THE ABOVE ITEMS (A-P) SHALL BE DEEMED AS AFFIRMATIVELY CHECKED/INITIALED. 1. Additionally, I give power to my Attorney-in-Fact to assign, transfer, convey and deliver to the Trustee of that certain Declaration of Trust referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 any and all of my property such as cash, stocks, bonds, securities, annuities and any other property of any kind whether real property or personal; to endorse and deliver to said trustee(s) any checks, drafts, certificates of deposit, notes receivable or other instruments for which I have an interest in as monies payable or belonging to me; to designate the Trustee, of said Trust, as the beneficiary any life insurance policies, employee benefit or pension plans or individual retirement accounts owned by me or in which I have an interest, and, in general, to do all things which I, as a grantor of a living trust, might do if present and capable. DPA/Asset Page 2 (of 4) PDF/103
  • 104. 2. Notwithstanding the above provisions, my Attorney-in-Fact shall have NO power to transact with assets/properties which have been transferred to said Trust either by me or by my Attorney-in-Fact unless the Trustee of said Trust expressly grants to my Attorney-in-Fact the right to act as a nominee Trustee or agent over any specific asset(s) held in said Trust. 3. Unless otherwise provided hereunder, this Power of Attorney shall spring into effect upon the execution of an opinion letter or medical certification of my attending physician (delivered to my Attorney-in-Fact) certifying my incapacity to carry on my normal fiduciary affairs because of a mental or physical impairment and shall continue therein until a certification from a licensed physician declares that the impairment is no longer effective or applicable. This Power of Attorney shall not be affected by the subsequent disability or incompetence of the principal. Notwithstanding the terms of this paragraph, to the extent this Power of Attorney is intended to be exercised in a jurisdiction not then currently recognizing its efficacy at a "future date" – based upon the occurrence of a future event or contingency – then this Power of Attorney shall be deemed as being effective immediately as to its application in any such jurisdiction. ________________ I understand the full importance of this Durable Power Of Attorney Over Assets document and I have emotional and mental capacity to execute such document. x________________________________ MARY A SMITH ACKNOWLEDGEMENT The Declarant signing this foregoing Power of Attorney for Over Assets is personally known to us or has provided proof of her identity, signed or acknowledged her signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as her health care representative, has not named either of us as a beneficiary of her estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address DPA/Asset Page 3 (of 4) PDF/104
  • 105. STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within Durable Power of Attorney Over Assets instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) DPA/Asset Page 4 (of 4)PDF/105 
  • 106. DURABLE AGENT NOTICE TO WHOM IT CONCERNS: I, ________________________________, the undersigned AFFIANT, named as the Durable (Attorney-in-Fact) Agent for HENRY J. SMITH, the principal, in that certain Durable Power of Attorney Over Assets document dated - the ______ day of ________________, ________: (Applicable statement checked by affiant) _____ Have accepted such appointment and shall act according to the power and authority granted to me as the durable attorney-in-fact for such named principal; further, I attest that the above named principal is (i) still alive, (ii) was competent at the time of the execution of said Power of Attorney and that (iii) such Power of Attorney remains valid and in full effect. _____ Have not accepted such appointment and shall decline forever my appointment as the durable attorney-in-fact for such named principal. _____ Have by succession, according to an appropriate document (concerning the first appointee) of (ii) Declination Certificate or (ii) Medical Certificate, attached hereto and made a part hereof, accept such appointment as the durable attorney-in-fact for such named principal. x________________________________ Affiant - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of ______________________, before me, _______________________, the undersigned Notary Public, personally appeared _________________________________, (Affiant), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/106
  • 107. DURABLE AGENT NOTICE TO WHOM IT CONCERNS: I, ________________________________, the undersigned AFFIANT, named as the Durable (Attorney-in-Fact) Agent for MARY A SMITH, the principal, in that certain Durable Power of Attorney Over Assets document dated - the ______ day of ________________, ________: (Applicable statement checked by affiant) _____ Have accepted such appointment and shall act according to the power and authority granted to me as the durable attorney-in-fact for such named principal; further, I attest that the above named principal is (i) still alive, (ii) was competent at the time of the execution of said Power of Attorney and that (iii) such Power of Attorney remains valid and in full effect. _____ Have not accepted such appointment and shall decline forever my appointment as the durable attorney-in-fact for such named principal. _____ Have by succession, according to an appropriate document (concerning the first appointee) of (ii) Declination Certificate or (ii) Medical Certificate, attached hereto and made a part hereof, accept such appointment as the durable attorney-in-fact for such named principal. x________________________________ Affiant - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of ______________________, before me, _______________________, the undersigned Notary Public, personally appeared _________________________________, (Affiant), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ____________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/107
  • 108. DURABLE POWER OF ATTORNEY – FOR HEALTH CARE – I, HENRY J. SMITH, a resident of Maricopa County, State of Arizona, do now declare this to be a Durable Power of Attorney for Health Care declaration for me under the laws of any jurisdiction I may be in at any time of my disability. 1. I hereby appoint MARY A SMITH, my spouse, as my true and lawful Attorney-in-Fact agent for health care. If my spouse is unable or unavailable to serve as my agent then I designate HENRY J SMITH, JR (as my alternate agent) to serve. Otherwise, ANN B SMITH shall serve (as my second alternate agent) if my first alternate agent cannot serve, in such case. 2. Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This Instrument Entirely – I hereby authorize my Attorney-in-Fact to perform the following acts if I become incapable of giving informed consent: A) REQUEST, RECEIVE, AND REVIEW ANY INFORMATION, VERBAL OR WRITTEN, REGARDING MY PHYSICAL CONDITION OR MENTAL HEALTH INCLUDING, BUT NOT LIMITED TO, MEDICAL AND HOSPITAL RECORDS AND CONSENT TO DISCLOSURE OF MY MEDICAL RECORDS; B) CONSENT, REFUSE TO CONSENT, OR WITHDRAW CONSENT TO ANY TREATMENT OR CARE TO MAINTAIN, TREAT, OR DIAGNOSE A PHYSICAL OR MENTAL CONDITION; AND, C) CONSENT TO WITHDRAWAL OR WITHHOLDING OF ANY TYPE OF TREATMENT THAT WOULD KEEP ME ALIVE - THIS POWER INCLUDES THE POWER TO WITHDRAW OR WITHHOLD HYDRATION OR FOOD IF I AM COMATOSE AND/OR TERMINALLY ILL. 3. I revoke any prior Durable Power of Attorney for Health Care. This Durable Power of Attorney for Health Care shall take precedence over any power of attorney (general, special, or medical) which I may sign upon my admission to any hospital or other health care facility. This Durable Power of Attorney for Health Care supplements (if necessary) any Living Will Declaration that I have executed. 4. It is my intention, by this instrument, to provide for my personal and medical assistance without the necessity of court action. Accordingly, I request, in the strongest possible terms that any court which may receive or act upon a petition for the appointment of a guardian for me should deny such petition so long as my Attorney-in-Fact is acting as appointed. If any court shall deem it necessary to appoint a guardian in spite of this request, then I request that my Attorney-in-Fact be appointed unless I have provided otherwise. DPA/Health Page 1 (of 4)PDF/108
  • 109. 5. This instrument shall be governed by the laws of the state of my domicile including its construction, interpretation and termination and, to the extent permitted by law, shall be applicable to wherever and in whatever state of the United States or foreign country I may be at the time. 6. If any part of any provision of this instrument shall be invalid or unenforceable under applicable law, such part shall be ineffective to the extent of such invalidity only, without affecting the remaining, valid provisions of this instrument. 7. This instrument may be amended or revoked by me. My Attorney-in-Fact (and any alternate) may be removed by my revocation or amendment by me. If this instrument has been recorded in the public records, then the instrument of revocation, amendment or removal shall be filed or recorded in the same public records. My Attorney-in-Fact may resign by the execution of a written resignation delivered to me, or if I am mentally incapacitated, by delivery to any person with whom I am residing or who has the care and custody of me, or in the case of an alternate, by delivery to my Attorney-in-Fact. 8. My Attorney-in-Fact shall have full power and authority to do so and perform all acts whatsoever requisite to be done in order to fully accomplish the aforementioned to all intents and purposes as I might or could do otherwise. I hereby ratify and confirm all that my Attorney-in-Fact shall do or cause to be done by virtue of this instrument. 9. Every physician, hospital, care provider, or other person, firm or corporation to which this instrument is presented to (or presented a photocopy hereof) is expressly authorized to honor and give effect to all instruments signed pursuant to the foregoing authority without inquiring as to the circumstances of their issuance or the disposition of the property delivered pursuant thereto. 10. For purposes of this instrument, I shall be considered to be disabled if I lack sufficient capacity to make or communicate responsible decisions concerning my welfare by reason of mental illness, mental deficiency, mental disorder, physical illness or disability, chronic use of drugs, chronic intoxication or other cause. This existence of such a disability shall be conclusively established by attaching to this instrument the sworn statement of my attending physician stating that he or she has examined me and believes that the existence of one (or more) of such stated conditions exists to cause my incapacity. 11. The validity of (i) my restoration of my competency or (ii) the declaration of my disability which gave rise to the effectiveness of this Durable Power of Attorney for Health Care may only be revoked by my express written revocation or by the express written revocation of my duly appointed conservator. 12. In the event that this Durable Power of Attorney for Health Care becomes effective by reason of my disability, my revocation shall be accompanied by a sworn statement of a physician stating that he or she (i) has examined me, (ii) believes that the condition giving rise to the effectiveness of this Durable Power of Attorney for Health Care has been removed and (iii) believes that I possess the understanding and capacity to make responsible decisions regarding my welfare. DPA/Health Page 2 (of 4)PDF/109
  • 110. WARNING TO PERSON EXECUTING THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY FOR HEALTH CARE. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:  THIS DOCUMENT GIVES THE PERSON YOU HAVE DESIGNATED, AS YOUR ATTORNEY-IN-FACT, THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU, SUBJECT TO ANY LIMITATIONS OR STATEMENT OF YOUR DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE CONSENT, REFUSAL TO CONSENT, OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU DO NOT DESIRE.  THE PERSON YOU HAVE DESIGNATED IN THIS DOCUMENT HAS A DUTY TO ACT IN ACCORDANCE WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN. IF YOUR DESIRES ARE UNKNOWN, YOUR ATTORNEY-IN-FACT IS TO ACT IN YOUR BEST INTERESTS.  UNLESS OTHERWISE SPECIFIED IN THIS DOCUMENT, YOUR ATTORNEY-IN- FACT HAS THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU; THIS MAY INCLUDE CONSENTING TO WITHHOLD TREATMENT WHICH COULD PROLONG YOUR LIFE.  NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF AS LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, NO TREATMENT OR ANY HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY BE ADMINISTERED OVER YOUR OBJECTION.  YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL, OR OTHER HEALTH CARE PROVIDER, ORALLY OR IN WRITING.  THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT.  IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.  THIS HEALTH CARE DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES WHO ARE NEITHER BENEFICIARIES OF YOUR ESTATE NOR RELATED BY BLOOD, MARRIAGE, OR ADOPTION AND PRESENT WHEN YOU SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC. DPA/Health Page 3 (of 4)PDF/110
  • 111. I hereby declare that I have executed this Durable Power of Attorney for Health Care on this day, the ______ day of _____________________, 2012, consisting of four (4) pages including the "warning" page (3) and this page. x________________________________ HENRY J. SMITH ACKNOWLEDGEMENT The Declarant signing this foregoing Power of Attorney for Health Care is personally known to us or has provided proof of his identity, signed or acknowledged his signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as his health care representative, has not named either of us as a beneficiary of his estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) DPA/Health Page 4 (of 4) PDF/111
  • 112. DURABLE POWER OF ATTORNEY – FOR HEALTH CARE – I, MARY A SMITH, a resident of Maricopa County, State of Arizona, do now declare this to be a Durable Power of Attorney for Health Care declaration for me under the laws of any jurisdiction I may be in at any time of my disability. 1. I hereby appoint HENRY J. SMITH, my spouse, as my true and lawful Attorney-in- Fact agent for health care. If my spouse is unable or unavailable to serve as my agent then I designate HENRY J SMITH, JR (as my alternate agent) to serve. Otherwise, ANN B SMITH shall serve (as my second alternate agent) if my first alternate agent cannot serve, in such case. 2. Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This Instrument Entirely – I hereby authorize my Attorney-in-Fact to perform the following acts if I become incapable of giving informed consent: A) REQUEST, RECEIVE, AND REVIEW ANY INFORMATION, VERBAL OR WRITTEN, REGARDING MY PHYSICAL CONDITION OR MENTAL HEALTH INCLUDING, BUT NOT LIMITED TO, MEDICAL AND HOSPITAL RECORDS AND CONSENT TO DISCLOSURE OF MY MEDICAL RECORDS; B) CONSENT, REFUSE TO CONSENT, OR WITHDRAW CONSENT TO ANY TREATMENT OR CARE TO MAINTAIN, TREAT, OR DIAGNOSE A PHYSICAL OR MENTAL CONDITION; AND, C) CONSENT TO WITHDRAWAL OR WITHHOLDING OF ANY TYPE OF TREATMENT THAT WOULD KEEP ME ALIVE - THIS POWER INCLUDES THE POWER TO WITHDRAW OR WITHHOLD HYDRATION OR FOOD IF I AM COMATOSE AND/OR TERMINALLY ILL. 3. I revoke any prior Durable Power of Attorney for Health Care. This Durable Power of Attorney for Health Care shall take precedence over any power of attorney (general, special, or medical) which I may sign upon my admission to any hospital or other health care facility. This Durable Power of Attorney for Health Care supplements (if necessary) any Living Will Declaration that I have executed. 4. It is my intention, by this instrument, to provide for my personal and medical assistance without the necessity of court action. Accordingly, I request, in the strongest possible terms that any court which may receive or act upon a petition for the appointment of a guardian for me should deny such petition so long as my Attorney-in-Fact is acting as appointed. If any court shall deem it necessary to appoint a guardian in spite of this request, then I request that my Attorney-in-Fact be appointed unless I have provided otherwise. DPA/Health Page 1 (of 4)PDF/112
  • 113. 5. This instrument shall be governed by the laws of the state of my domicile including its construction, interpretation and termination and, to the extent permitted by law, shall be applicable to wherever and in whatever state of the United States or foreign country I may be at the time. 6. If any part of any provision of this instrument shall be invalid or unenforceable under applicable law, such part shall be ineffective to the extent of such invalidity only, without affecting the remaining, valid provisions of this instrument. 7. This instrument may be amended or revoked by me. My Attorney-in-Fact (and any alternate) may be removed by my revocation or amendment by me. If this instrument has been recorded in the public records, then the instrument of revocation, amendment or removal shall be filed or recorded in the same public records. My Attorney-in-Fact may resign by the execution of a written resignation delivered to me, or if I am mentally incapacitated, by delivery to any person with whom I am residing or who has the care and custody of me, or in the case of an alternate, by delivery to my Attorney-in-Fact. 8. My Attorney-in-Fact shall have full power and authority to do so and perform all acts whatsoever requisite to be done in order to fully accomplish the aforementioned to all intents and purposes as I might or could do otherwise. I hereby ratify and confirm all that my Attorney-in-Fact shall do or cause to be done by virtue of this instrument. 9. Every physician, hospital, care provider, or other person, firm or corporation to which this instrument is presented to (or presented a photocopy hereof) is expressly authorized to honor and give effect to all instruments signed pursuant to the foregoing authority without inquiring as to the circumstances of their issuance or the disposition of the property delivered pursuant thereto. 10. For purposes of this instrument, I shall be considered to be disabled if I lack sufficient capacity to make or communicate responsible decisions concerning my welfare by reason of mental illness, mental deficiency, mental disorder, physical illness or disability, chronic use of drugs, chronic intoxication or other cause. This existence of such a disability shall be conclusively established by attaching to this instrument the sworn statement of my attending physician stating that he or she has examined me and believes that the existence of one (or more) of such stated conditions exists to cause my incapacity. 11. The validity of (i) my restoration of my competency or (ii) the declaration of my disability which gave rise to the effectiveness of this Durable Power of Attorney for Health Care may only be revoked by my express written revocation or by the express written revocation of my duly appointed conservator. 12. In the event that this Durable Power of Attorney for Health Care becomes effective by reason of my disability, my revocation shall be accompanied by a sworn statement of a physician stating that he or she (i) has examined me, (ii) believes that the condition giving rise to the effectiveness of this Durable Power of Attorney for Health Care has been removed and (iii) believes that I possess the understanding and capacity to make responsible decisions regarding my welfare. DPA/Health Page 2 (of 4)PDF/113
  • 114. WARNING TO PERSON EXECUTING THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY FOR HEALTH CARE. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:  THIS DOCUMENT GIVES THE PERSON YOU HAVE DESIGNATED, AS YOUR ATTORNEY-IN-FACT, THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU, SUBJECT TO ANY LIMITATIONS OR STATEMENT OF YOUR DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE CONSENT, REFUSAL TO CONSENT, OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU DO NOT DESIRE.  THE PERSON YOU HAVE DESIGNATED IN THIS DOCUMENT HAS A DUTY TO ACT IN ACCORDANCE WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN. IF YOUR DESIRES ARE UNKNOWN, YOUR ATTORNEY-IN-FACT IS TO ACT IN YOUR BEST INTERESTS.  UNLESS OTHERWISE SPECIFIED IN THIS DOCUMENT, YOUR ATTORNEY-IN- FACT HAS THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU; THIS MAY INCLUDE CONSENTING TO WITHHOLD TREATMENT WHICH COULD PROLONG YOUR LIFE.  NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF AS LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, NO TREATMENT OR ANY HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY BE ADMINISTERED OVER YOUR OBJECTION.  YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL, OR OTHER HEALTH CARE PROVIDER, ORALLY OR IN WRITING.  THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT.  IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.  THIS HEALTH CARE DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES WHO ARE NEITHER BENEFICIARIES OF YOUR ESTATE NOR RELATED BY BLOOD, MARRIAGE, OR ADOPTION AND PRESENT WHEN YOU SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC. DPA/Health Page 3 (of 4)PDF/114
  • 115. I hereby declare that I have executed this Durable Power of Attorney for Health Care on this day, the ______ day of _____________________, 2012, consisting of four (4) pages including the "warning" page (3) and this page. x________________________________ MARY A SMITH ACKNOWLEDGEMENT The Declarant signing this foregoing Power of Attorney for Health Care is personally known to us or has provided proof of her identity, signed or acknowledged her signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as her health care representative, has not named either of us as a beneficiary of her estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) DPA/Health Page 4 (of 4) PDF/115
  • 116. HEALTH CARE AGENT NOTICE TO WHOM IT CONCERNS: I, ________________________________, the undersigned AFFIANT, named as the Health Care Agent for HENRY J. SMITH, the Principal, in that certain - Durable Power of Attorney for Health Care document dated - the ______ day of ________________, ________: declare and state the following: I hereby accept this appointment and agree to serve as agent for the Principal concerning his Health Care decisions in the event that he is incapable in making such decisions himself. I understand that I have a duty to act consistently with the desires of the Principal as expressed in such appointment. I understand that said document gives me authority over health care decisions for him only if he becomes incapable and that I must act in good faith in exercising my authority under such appointment. I acknowledge that the principal, if competent, may revoke said Health Care Power of Attorney at any time and in any manner. If I choose to withdraw during the time the principal is competent, I must notify him of my decision. If I choose to withdraw when the principal is incapable of making his own health care decisions then I must notify his physician. x________________________________ Affiant STATE OF _______________________ COUNTY OF _____________________ On this ______ day of ________________, ________, before me, __________________, the undersigned, personally appeared _________________________________, (Affiant), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/116
  • 117. HEALTH CARE AGENT NOTICE TO WHOM IT CONCERNS: I, ________________________________, the undersigned AFFIANT, named as the Health Care Agent for MARY A SMITH, the Principal, in that certain - Durable Power of Attorney for Health Care document dated - the ______ day of ________________, ________: declare and state the following: I hereby accept this appointment and agree to serve as agent for the Principal concerning her Health Care decisions in the event that she is incapable in making such decisions herself. I understand that I have a duty to act consistently with the desires of the Principal as expressed in such appointment. I understand that said document gives me authority over health care decisions for her only if she becomes incapable and that I must act in good faith in exercising my authority under such appointment. I acknowledge that the principal, if competent, may revoke said Health Care Power of Attorney at any time and in any manner. If I choose to withdraw during the time the principal is competent, I must notify her of my decision. If I choose to withdraw when the principal is incapable of making her own health care decisions then I must notify her physician. x________________________________ Affiant STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ________, before me, ___________________, the undersigned, personally appeared _________________________________, (Affiant), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)PDF/117
  • 118. LIVING WILL DECLARATION (preceded by) ADVANCED HEALTH CARE DIRECTIVES Introduction This eighth section contains your Living Will and Advance Health Care Directive. NOTE: The Advance Health Care Directive is the first document in this Section because, if properly filled out, it is generally recognized now as the modern replacement of the Living Will if you wish to use it. Nevertheless, the Advance Health Care Directive must be filled out to be effective. Lately, many health care institutions have necessitated the use of the DPAHC in conjunction with a Living Will to carry out the decrees of the Living Will; therefore, your appointed agents for your DPAHC must be the same as those of your Living Will. It is wise, therefore, to keep both documents together in your Portfolio. In its simplest terms, the Living Will and/or Advance Health Care Directive is a statement of the desire to not be artificially sustained when certain death would occur if not for the use of machines to keep ones body functioning. One of the primary reasons of having a Living Will is to avoid a spend-down of resources to sustain ones body confined to a vegetative or comatose state, i.e. - kept alive by machines only. This Living Will also appoints guardians of your person and guardians on your behalf. This means that your Living Will agents, who are the same as those named in your DPAHC – unless you have identified other agents in your Health Care Directive – would be appointed to take care of you in the event of your incapacitation and would have the ability to file a law suit (or hire legal counsel to defend you in court) on your behalf in the event of your incapacitation. Be careful not to confuse this agency with the agency you have granted to your fiduciaries, i.e. - the (i) agents of your Durable Power of Attorney Over Assets, (ii) the personal representatives of your Last Will & Testament and (iii) the successor trustees of your Revocable Living Trust. _______________PDF/118
  • 119. PLEASE NOTICE The following document(s) is referred to as an – ADVANCE DIRECTIVE for HEALTH CARE An Advance Directive (for health care) can work with or without a Durable Power of Attorney for Health Care and is generally used in conjunction with a Living Will (as does a Health Care Power of Attorney). However, you do not have to fill out and sign this form. You may sign the Advance Directive now or at a later date or not at all. Whatever choice you make, it is recommended that you review the document at your earliest convenience. It is not the place or the responsibility of a financial or tax advisor to explain matters pertaining to health care documents. If you do not understand any of the components of the Advance Directive or how it works in conjunction with any other health care document(s) that you may have executed, then it is recommended that you seek out a doctor or other medical assistant to explain the issues that are unclear to you. ____________________PDF/119
  • 120. ADVANCE HEALTH CARE DIRECTIVE PART  “A”    – IMPORTANT INFORMATION / PLEASE READ This is an important legal document. It can control optional but critical decisions about your health care. Before signing, consider these important facts: 1) YOU HAVE THE RIGHT TO NAME A PERSON TO DIRECT AND CONTROL YOUR HEALTH CARE PREFERENCES – REFERRED TO AS YOUR "HEALTH CARE AGENT" – IN PART "C" OF THIS FORM. YOU MAY APPOINT A PRIMARY PHYSICIAN – TO ADMINISTER YOUR HEALTH CARE DIRECTIVES – IN  PART  “F”  OF  THIS  FORM. 2) YOU CAN WRITE ANY RESTRICTIONS HEREIN THAT YOU MAY WANT ON HOW YOUR AGENT IS TO MAKE DECISIONS ON YOUR BEHALF. YOUR AGENT MUST FOLLOW YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN BY YOU. IF YOUR DESIRES ARE UNKNOWN, YOUR AGENT IS TO ACT IN YOUR BEST INTEREST. YOUR AGENT CAN RESIGN AT ANY TIME. 3) UNLESS OTHERWISE INDICATED HEREIN OR IN OTHER DOCUMENTATION, YOUR AGENT WILL HAVE THE RIGHT TO: (A) CONSENT OR REFUSE ANY CARE, TREATMENT, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR OTHERWISE AFFECT YOUR PHYSICAL OR MENTAL CONDITION; (B) SELECT OR DISCHARGE HEALTH CARE PROVIDERS AND INSTITUTIONS; (C) APPROVE OR DISAPPROVE DIAGNOSTIC TESTS, SURGICAL PROCEDURES, AND PROGRAMS OF MEDICATION; (D) DIRECT THE PROVISION, WITHHOLDING, OR WITHDRAWAL OF ARTIFICIAL NUTRITION AND HYDRATION AND ALL OTHER FORMS OF HEALTH CARE, INCLUDING CARDIOPULMONARY RESUSCITATION; (E) MAKE ANATOMICAL GIFTS, (F) AUTHORIZE AN AUTOPSY, AND (G) DIRECT DISPOSITION OF REMAINS. 4) YOU HAVE THE RIGHT TO   GIVE   SPECIFIC   “CHECK   THE   BOX”   &   WRITTEN INSTRUCTIONS FOR HEALTH CARE PROVIDERS TO FOLLOW IF YOU BECOME UNABLE TO DIRECT YOUR OWN CARE - BY USING PART "B" OF THIS FORM. 5) THIS FORM IS VALID ONLY IF YOU SIGN IT VOLUNTARILY AND WHEN YOU ARE OF SOUND MIND. IF YOU DO NOT WANT AN ADVANCE DIRECTIVE HEREIN, YOU DO NOT HAVE TO SIGN THIS FORM. 6) UNLESS YOU HAVE LIMITED THE DURATION OF THIS ADVANCE DIRECTIVE, IT WILL NOT EXPIRE. IF YOU HAVE SET AN EXPIRATION DATE AND YOU BECOME UNABLE TO DIRECT YOUR HEALTH CARE AGENT BEFORE THAT DATE, THIS ADVANCE DIRECTIVE WILL NOT EXPIRE UNTIL YOU ARE ABLE TO MAKE THOSE DECISIONS AGAIN. 7) YOU MAY REVOKE THIS DOCUMENT AT ANY TIME. TO DO SO, NOTIFY YOUR AGENT AND YOUR HEALTH CARE PROVIDER OF THE REVOCATION. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO DECIDE ON YOUR OWN HEALTH CARE AS LONG AS YOU ARE ABLE TO DO SO. 8) YOU MAY CROSS OUT WORDS THAT DONT EXPRESS YOUR WISHES OR ADD WORDS THAT BETTER EXPRESS YOUR WISHES; INITIAL ALL CHANGES YOU MAKE. FOR THIS DOCUMENT TO BE LEGALLY VALID, YOU MUST SIGN IT UNDER A NOTARY PUBLIC. Adv/Dir Page 1 (of 8)PDF/120
  • 121. PART  “B”    – HEALTH CARE DIRECTIVES BY: NAME: HENRY J. SMITH ADDRESS: 28 Wilson St CITYSTZIP: Phoenix, AZ 8501 1) I REVOKE ALL PRIOR Advance Directives signed by me. This document shall remain valid and effective in the event that I become incapacitated. A copy and/or an electronic file of this form shall have the same effect as the original document. 2) Close to Death / End of Life – If I am (a) close to death where tube feeding and/or life support would only postpone the moment of my death, and/or (b) unconscious and it is highly unlikely that I will ever regain consciousness again, and/or (c) I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize loved ones, and it is very unlikely that my condition will substantially improve, then I request that the following actions be taken (or not taken): Initial as applicable (tube feeding): Initial as applicable (life support): _____ I want tube feeding/hydration _____ I want life support _____ As my Agent recommends _____ As my Agent recommends _____ As my Physician recommends _____ As my Physician recommends _____ I want no tube feeding/hydration _____ I want no life support _____ See my written directives herein _____ See my written directives herein (OR) / Initial as applicable (state your general directives): _____ I CHOOSE NOT TO PROLONG MY LIFE – if (1) I have an incurable and irreversible condition that will likely result in my death within a relatively short time, or (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the apparent risks and burdens of treatment would outweigh the expected benefits. _____ I CHOOSE TO PROLONG MY LIFE. I want my life to be prolonged as long as possible within the limits of generally accepted health care standards. Adv/Dir Page 2 (of 8)PDF/121
  • 122. 3) My Agent May Decide – UNLESS OTHERWISE INDICATED IN THIS FORM, and/or to the extent my wishes are unknown, my agent shall make ALL health care decisions for me in accordance with what my agent determines to be in my best interest – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4) Treatment for Pain – I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5) Additional Health Care (and/or Mental Health Care) Instructions – _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Adv/Dir Page 3 (of 8)PDF/122
  • 123. PART  “C”    – APPOINTMENT OF HEALTH CARE AGENT(S) (NOTE: You MAY NOT to appoint your doctor, an employee of your doctor, or any owner, operator or employee of your health care facility as your Health Care Agent.) THE FOLLOWING ARE APPOINTED to serve as my Health Care Agents per this document successively in the order shown; and unless otherwise noted or appointed in the Additional Instructions section, the following shall also serve as my Conservator, if ever that may be required, in the order shown (NOTICE: If I have not made any name entries in this page then my Health Care Agent[s] identified on my Health Care Power of Attorney shall serve as my agent[s] for this Advance Directive): Primary H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) 1st Alternate H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) 2nd Alternate H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) Adv/Dir Page 4 (of 8)PDF/123
  • 124. PART  “D”    – AGENT’S  AUTHORITY  &  ORGAN  DONATION (NOTE: You have a right to determine   when   your   agent’s   authority   becomes   effective,   which is either [a] when your primary physician determines that you are unable to make decisions on your own or [b] immediately. A notice should be given to your primary physician  when  an  agent’s  authority  becomes effective): 1)    Agent’s  Effective  Date  – My  agent’s  authority  & obligation becomes effective only when my primary physician determines that I am unable to make my own health care decisions (unless I initial the following stipulation). _____ My agent’s  authority  &  obligation  becomes  effective  immediately. 2) Agents  “Post  Death” Authority – UNLESS OTHERWISE NOTED in this or a separate document, my agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 3) Organ Donation Directive(s) – _____ I DO NOT AUTHORIZE that any organs/tissue/parts be donated from my body. _____ I AUTHORIZE MY AGENT to donate needed organs/tissue/parts from my body. _____ I AUTHORIZE SPECIFIC-PURPOSE donations – shown as circled: Transplant Therapy Research Education _____ I AUTHORIZE CERTAIN LIMITED donations as follows: ______________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________ Adv/Dir Page 5 (of 8)PDF/124
  • 125. PART  “E”    – OTHER HEALTH CARE DOCUMENTS (NOTE:   A   "Health   Care   Power   of   Attorney”   is   any   document   you   may   have   executed   to   appoint an agent to make certain health care decisions on your behalf when you are unable to do so. A “Living Will” is any document you may have executed to state your wishes as to the extension or termination of your life when in a terminal condition of such that you are unable to make such a decision.) 1) Health Care Power of Attorney – Initial one or more as applicable: _____ I have executed a Health Care Power of Attorney and IT IS TO REMAIN IN EFFECT. Notwithstanding, if any provision selected in this Advance Directive is not consistent with the provisions in my Health Care Power of Attorney then any such conflicting provision selected in this Advance Directive shall instead apply. _____ I have previously executed a Health Care Power of Attorney and I NOW REVOKE IT. Notwithstanding this revocation, if my medical treatment is being administered in a jurisdiction that otherwise requires the application of a portion or all of the terms of my Health Care Power of Attorney then any such required stipulations shall apply. _____ I currently DO NOT have a separate Health Care Power of Attorney. 2) Living Will – Initial one or more as applicable: _____ I have executed a Living Will and IT IS TO REMAIN IN EFFECT. Notwithstanding, if any provision in this Advance Directive is determined to be in conflict with any provision in my Living Will then any such conflicting provision selected in my Advance Directive shall apply. _____ I have previously executed a Living Will and I NOW REVOKE IT in its entirety. Notwithstanding this revocation, if my medical treatment is being administered in a jurisdiction that necessitates the application of a part or all of the terms of my Living Will then any such required stipulations of my Living Will shall apply. _____ I currently DO NOT have a separate Living Will. 3)    Additional  Information  Regarding  “Other  Documents”  – _____________________________________________________________________ _____________________________________________________________________ Adv/Dir Page 6 (of 8)PDF/125
  • 126. PART  ”F”    – Appointment of Primary & Alternate Physician (NOTE: You have a right to designate a primary physician as applied to this directive. If you appoint a primary physician [and an alternate physician] who is not then available to act in that capacity on your behalf then the physician who would be attending to you at that time shall be allowed to act instead in their behalf): Initial As Applicable: _____ I DO NOT DESIGNATE a primary physician. _____ I DESIGNATE a primary physician, as follows: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number _____ I ALSO DESIGNATE an alternate physician as my physician if my primary physician named above is not willing, able, or reasonably available to act as my physician: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number Adv/Dir Page 7 (of 8)PDF/126
  • 127. I hereby declare that I have executed this Advance Directive on this day, the ______ day of __________________, 2012,  consisting  of  eight  (8)  pages  including  the  "information”  page  (1)   and this acknowledgement page. x________________________________ HENRY J. SMITH The Declarant signing this Advance Directive (i) is personally known to us or has provided proof of his identity, (ii) signed or acknowledged his signature on this Advance Directive in our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence, (iv) has not appointed either of us as health care representative or alternative representative as provided herein, and (v) is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address - ACKNOWLEDGEMENT - STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) Adv/Dir Page 8 (of 8) PDF/127
  • 128. DURABLE HIPAA STATEMENT – Release & Authorization – I, HENRY J. SMITH, the undersigned, being over eighteen (18) years of age, of sound mind and memory and not acting under duress or undue influence, declare this to be my Durable Statement concerning health care privacy issues addressed by certain federal regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 42 USC §1320d, 45 CFR 160-164, and all other applicable state and federal law and defining regulations. Notwithstanding any other document that I may have signed earlier to the contrary, I hereby consent to the full disclosure of any and all of my medical records by any physician or psychiatrist or any other health care provider as it may be deemed necessary or expedient, from time to time, for the purposes of rendering a medical opinion as to my physical and/or mental inability to act on my own behalf in making personal, health related, financial/fiduciary or other similar decisions. I authorize any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and the Medical Information Bureau Inc. or other health-care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to the agent(s) as hereinafter described, without restriction, ALL of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition. The persons designated as my agents for purposes of this agreement include: (a) all persons designated as health care agents and/or attorney-in-fact in any Power of Attorney for Health Care, Advance Health Care Directive, or similar document executed by me and/or (b) as trustees under any living trust executed by me. The authority given my agent(s) shall supersede any prior agreement that I may have made with my health-care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health-care provider. I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. x________________________________ HENRY J. SMITH HIPAA Page 1 (of 2) PDF/128
  • 129. ACKNOWLEDGEMENT STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument (Durable HIPAA Statement), consisting of 2 pages of which this is the 2nd, and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) HIPAA Page 2 (of 2) PDF/129
  • 130. ADVANCE HEALTH CARE DIRECTIVE PART  “A”    – IMPORTANT INFORMATION / PLEASE READ This is an important legal document. It can control optional but critical decisions about your health care. Before signing, consider these important facts: 1) YOU HAVE THE RIGHT TO NAME A PERSON TO DIRECT AND CONTROL YOUR HEALTH CARE PREFERENCES – REFERRED TO AS YOUR "HEALTH CARE AGENT" – IN PART "C" OF THIS FORM. YOU MAY APPOINT A PRIMARY PHYSICIAN – TO ADMINISTER YOUR HEALTH CARE DIRECTIVES – IN  PART  “F”  OF  THIS  FORM. 2) YOU CAN WRITE ANY RESTRICTIONS HEREIN THAT YOU MAY WANT ON HOW YOUR AGENT IS TO MAKE DECISIONS ON YOUR BEHALF. YOUR AGENT MUST FOLLOW YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN BY YOU. IF YOUR DESIRES ARE UNKNOWN, YOUR AGENT IS TO ACT IN YOUR BEST INTEREST. YOUR AGENT CAN RESIGN AT ANY TIME. 3) UNLESS OTHERWISE INDICATED HEREIN OR IN OTHER DOCUMENTATION, YOUR AGENT WILL HAVE THE RIGHT TO: (A) CONSENT OR REFUSE ANY CARE, TREATMENT, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR OTHERWISE AFFECT YOUR PHYSICAL OR MENTAL CONDITION; (B) SELECT OR DISCHARGE HEALTH CARE PROVIDERS AND INSTITUTIONS; (C) APPROVE OR DISAPPROVE DIAGNOSTIC TESTS, SURGICAL PROCEDURES, AND PROGRAMS OF MEDICATION; (D) DIRECT THE PROVISION, WITHHOLDING, OR WITHDRAWAL OF ARTIFICIAL NUTRITION AND HYDRATION AND ALL OTHER FORMS OF HEALTH CARE, INCLUDING CARDIOPULMONARY RESUSCITATION; (E) MAKE ANATOMICAL GIFTS, (F) AUTHORIZE AN AUTOPSY, AND (G) DIRECT DISPOSITION OF REMAINS. 4) YOU HAVE THE RIGHT   TO   GIVE   SPECIFIC   “CHECK   THE   BOX”   &   WRITTEN INSTRUCTIONS FOR HEALTH CARE PROVIDERS TO FOLLOW IF YOU BECOME UNABLE TO DIRECT YOUR OWN CARE - BY USING PART "B" OF THIS FORM. 5) THIS FORM IS VALID ONLY IF YOU SIGN IT VOLUNTARILY AND WHEN YOU ARE OF SOUND MIND. IF YOU DO NOT WANT AN ADVANCE DIRECTIVE HEREIN, YOU DO NOT HAVE TO SIGN THIS FORM. 6) UNLESS YOU HAVE LIMITED THE DURATION OF THIS ADVANCE DIRECTIVE, IT WILL NOT EXPIRE. IF YOU HAVE SET AN EXPIRATION DATE AND YOU BECOME UNABLE TO DIRECT YOUR HEALTH CARE AGENT BEFORE THAT DATE, THIS ADVANCE DIRECTIVE WILL NOT EXPIRE UNTIL YOU ARE ABLE TO MAKE THOSE DECISIONS AGAIN. 7) YOU MAY REVOKE THIS DOCUMENT AT ANY TIME. TO DO SO, NOTIFY YOUR AGENT AND YOUR HEALTH CARE PROVIDER OF THE REVOCATION. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO DECIDE ON YOUR OWN HEALTH CARE AS LONG AS YOU ARE ABLE TO DO SO. 8) YOU MAY CROSS OUT WORDS THAT DONT EXPRESS YOUR WISHES OR ADD WORDS THAT BETTER EXPRESS YOUR WISHES; INITIAL ALL CHANGES YOU MAKE. FOR THIS DOCUMENT TO BE LEGALLY VALID, YOU MUST SIGN IT UNDER A NOTARY PUBLIC. Adv/Dir Page 1 (of 8)PDF/130
  • 131. PART  “B”    – HEALTH CARE DIRECTIVES BY: NAME: MARY A SMITH ADDRESS: 28 Wilson St CITYSTZIP: Phoenix, AZ 8501 1) I REVOKE ALL PRIOR Advance Directives signed by me. This document shall remain valid and effective in the event that I become incapacitated. A copy and/or an electronic file of this form shall have the same effect as the original document. 2) Close to Death / End of Life – If I am (a) close to death where tube feeding and/or life support would only postpone the moment of my death, and/or (b) unconscious and it is highly unlikely that I will ever regain consciousness again, and/or (c) I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize loved ones, and it is very unlikely that my condition will substantially improve, then I request that the following actions be taken (or not taken): Initial as applicable (tube feeding): Initial as applicable (life support): _____ I want tube feeding/hydration _____ I want life support _____ As my Agent recommends _____ As my Agent recommends _____ As my Physician recommends _____ As my Physician recommends _____ I want no tube feeding/hydration _____ I want no life support _____ See my written directives herein _____ See my written directives herein (OR) / Initial as applicable (state your general directives): _____ I CHOOSE NOT TO PROLONG MY LIFE – if (1) I have an incurable and irreversible condition that will likely result in my death within a relatively short time, or (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the apparent risks and burdens of treatment would outweigh the expected benefits. _____ I CHOOSE TO PROLONG MY LIFE. I want my life to be prolonged as long as possible within the limits of generally accepted health care standards. Adv/Dir Page 2 (of 8)PDF/131
  • 132. 3) My Agent May Decide – UNLESS OTHERWISE INDICATED IN THIS FORM, and/or to the extent my wishes are unknown, my agent shall make ALL health care decisions for me in accordance with what my agent determines to be in my best interest – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4) Treatment for Pain – I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5) Additional Health Care (and/or Mental Health Care) Instructions – _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Adv/Dir Page 3 (of 8)PDF/132
  • 133. PART  “C”    – APPOINTMENT OF HEALTH CARE AGENT(S) (NOTE: You MAY NOT to appoint your doctor, an employee of your doctor, or any owner, operator or employee of your health care facility as your Health Care Agent.) THE FOLLOWING ARE APPOINTED to serve as my Health Care Agents per this document successively in the order shown; and unless otherwise noted or appointed in the Additional Instructions section, the following shall also serve as my Conservator, if ever that may be required, in the order shown (NOTICE: If I have not made any name entries in this page then my Health Care Agent[s] identified on my Health Care Power of Attorney shall serve as my agent[s] for this Advance Directive): Primary H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) 1st Alternate H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) 2nd Alternate H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) Adv/Dir Page 4 (of 8)PDF/133
  • 134. PART  “D”    – AGENT’S  AUTHORITY  &  ORGAN  DONATION (NOTE:   You   have   a   right   to   determine   when   your   agent’s   authority   becomes   effective,   which is either [a] when your primary physician determines that you are unable to make decisions on your own or [b] immediately. A notice should be given to your primary physician  when  an  agent’s  authority  becomes  effective): 1)    Agent’s  Effective  Date  – My  agent’s  authority  & obligation becomes effective only when my primary physician determines that I am unable to make my own health care decisions (unless I initial the following stipulation). _____  My  agent’s  authority  &  obligation  becomes  effective  immediately. 2) Agents  “Post  Death” Authority – UNLESS OTHERWISE NOTED in this or a separate document, my agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 3) Organ Donation Directive(s) – _____ I DO NOT AUTHORIZE that any organs/tissue/parts be donated from my body. _____ I AUTHORIZE MY AGENT to donate needed organs/tissue/parts from my body. _____ I AUTHORIZE SPECIFIC-PURPOSE donations – shown as circled: Transplant Therapy Research Education _____ I AUTHORIZE CERTAIN LIMITED donations as follows: ______________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________ Adv/Dir Page 5 (of 8)PDF/134
  • 135. PART  “E”    – OTHER HEALTH CARE DOCUMENTS (NOTE:   A   "Health   Care   Power   of   Attorney”   is   any   document   you   may   have   executed   to   appoint an agent to make certain health care decisions on your behalf when you are unable to do so. A “Living Will” is any document you may have executed to state your wishes as to the extension or termination of your life when in a terminal condition of such that you are unable to make such a decision.) 1) Health Care Power of Attorney – Initial one or more as applicable: _____ I have executed a Health Care Power of Attorney and IT IS TO REMAIN IN EFFECT. Notwithstanding, if any provision selected in this Advance Directive is not consistent with the provisions in my Health Care Power of Attorney then any such conflicting provision selected in this Advance Directive shall instead apply. _____ I have previously executed a Health Care Power of Attorney and I NOW REVOKE IT. Notwithstanding this revocation, if my medical treatment is being administered in a jurisdiction that otherwise requires the application of a portion or all of the terms of my Health Care Power of Attorney then any such required stipulations therein shall apply. _____ I currently DO NOT have a separate Health Care Power of Attorney. 2) Living Will – Initial one or more as applicable: _____ I have executed a Living Will and IT IS TO REMAIN IN EFFECT. Notwithstanding, if any provision in this Advance Directive is determined to be in conflict with any provision in my Living Will then any such conflicting provision selected in my Advance Directive shall apply. _____ I have previously executed a Living Will and I NOW REVOKE IT in its entirety. Notwithstanding this revocation, if my medical treatment is being administered in a jurisdiction that necessitates the application of a part or all of the terms of my Living Will then any such required stipulations of my Living Will shall apply. _____ I currently DO NOT have a separate Living Will. 3)    Additional  Information  Regarding  “Other  Documents”  – _____________________________________________________________________ _____________________________________________________________________ Adv/Dir Page 6 (of 8)PDF/135
  • 136. PART  “F”    – Appointment of Primary & Alternate Physician (NOTE: You have a right to designate a primary physician as applied to this directive. If you appoint a primary physician [and an alternate physician] who is not then available to act in that capacity on your behalf then the physician who would be attending to you at that time shall be allowed to act instead in their behalf): Initial As Applicable: _____ I DO NOT DESIGNATE a primary physician. _____ I DESIGNATE a primary physician, as follows: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number _____ I ALSO DESIGNATE an alternate physician as my physician if my primary physician named above is not willing, able, or reasonably available to act as my physician: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number Adv/Dir Page 7 (of 8)PDF/136
  • 137. I hereby declare that I have executed this Advance Directive on this day, the ______ day of __________________, 2012,  consisting  of  eight  (8)  pages  including  the  "information”  page  (1)   and this acknowledgement page. x________________________________ MARY A SMITH The Declarant signing this Advance Directive (i) is personally known to us or has provided proof of her identity, (ii) signed or acknowledged her signature on this Advance Directive in our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence, (iv) has not appointed either of us as health care representative or alternative representative as provided herein, and (v) is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address - ACKNOWLEDGEMENT - STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) Adv/Dir Page 8 (of 8) PDF/137
  • 138. DURABLE HIPAA STATEMENT – Release & Authorization – I, MARY A SMITH, the undersigned, being over eighteen (18) years of age, of sound mind and memory and not acting under duress or undue influence, declare this to be my Durable Statement concerning health care privacy issues addressed by certain federal regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 42 USC §1320d, 45 CFR 160-164, and all other applicable state and federal law and defining regulations. Notwithstanding any other document that I may have signed earlier to the contrary, I hereby consent to the full disclosure of any and all of my medical records by any physician or psychiatrist or any other health care provider as it may be deemed necessary or expedient, from time to time, for the purposes of rendering a medical opinion as to my physical and/or mental inability to act on my own behalf in making personal, health related, financial/fiduciary or other similar decisions. I authorize any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and the Medical Information Bureau Inc. or other health-care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to the agent(s) as hereinafter described, without restriction, ALL of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition. The persons designated as my agents for purposes of this agreement include: (a) all persons designated as health care agents and/or attorney-in-fact in any Power of Attorney for Health Care, Advance Health Care Directive, or similar document executed by me and/or (b) as trustees under any living trust executed by me. The authority given my agent(s) shall supersede any prior agreement that I may have made with my health-care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health-care provider. I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. x________________________________ MARY A SMITH HIPAA Page 1 (of 2) PDF/138
  • 139. ACKNOWLEDGEMENT STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument (Durable HIPAA Statement), consisting of 2 pages of which this is the 2nd, and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) HIPAA Page 2 (of 2) PDF/139
  • 140. ALTERNATIVE "PRO-LIFE" LIVING WILL w/HEALTH CARE DECLARATION I, HENRY J. SMITH (the   “Declarant”),   now   residing   at   Maricopa County, State of Arizona, being of sound mind and not under or subject to duress, fraud, or undue influence, intending to create a "Pro-Life" Health Care Declaration do voluntarily state my advance instructions relating to my medical treatment and care. I strongly believe in pro-life principles and   I   do   not   agree   with   “Living   Wills”   and   other   similar   directives   biased in favor of death. This Health Care Declaration is to be interpreted in favor of continued life. If I am unable to give directions regarding the use of life-sustaining treatment, it is my intention that this Health Care Declaration shall be honored by my family, physicians and care providers as the final expression of my instructions relating to my medical treatment or care. I am a competent adult who understands and accepts the consequences, purposes and effects of this document. INTENDED APPLICABILITY. The provisions of this Health Care Declaration apply to any diagnosis, whether I am in a terminal condition, a permanently unconscious state or otherwise. These provisions are effective during any period of time in which I am unable to communicate my informed consent because of illness or injury. This Health Care Declaration is valid unless revoked. GENERAL INSTRUCTIONS. Most of what I state here is general in nature since I cannot anticipate all the possible circumstances of a future illness. I direct that those caring for me avoid doing anything which is contrary to my pro-life principles and related Christian principals. If I am in a terminal condition, I ask that I be told of this so that I might prepare myself for death. I instruct each person who may treat me or care for me in illness or injury, or who otherwise may exercise or influence dominion or control over my body, that nothing shall be done or omitted to be done with the intent to cause my death. Notwithstanding any other document I may have signed, I am not to be denied food or water as long as my body is able to assimilate them. Mechanical or artificial means are to be utilized if necessary to assure me food and water. Medical treatment and care are to be provided if necessary to cure, remedy, or relieve  the  symptoms  of  my  condition.    Evaluation  of  “quality  of  life”  is  not  to  be  a  factor.    I   want to be kept clean and comfortable. Adequate efforts should be taken to relieve my pain though I do not want to be overmedicated to the point where I am unable to comprehend my situation and communicate with those around me. I understand the purpose and effect of this document and, after careful deliberation, hereby sign my name to this Health Care Declaration on this ______ day of __________________, 2012. ________________________________ HENRY J. SMITH P/L Living Will Page 1 (of 2)PDF/140 
  • 141. NOTE: THIS "PRO-LIFE" HEALTH CARE DECLARATION SHOULD BE (1) SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE AND (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC. The Declarant who has signed this Pro-Life Living Will & Health Care Declaration consisting of two pages of which this is the second page (i) is personally known to us or has provided proof of his identity, (ii) signed or acknowledged his signature on this Declaration in our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence, (iv) has not appointed either of us as health care representative or alternative representative as provided herein, and (v) is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address - ACKNOWLEDGEMENT - STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) P/L Living Will Page 2 (of 2) PDF/141
  • 142. ALTERNATIVE "PRO-LIFE" LIVING WILL w/HEALTH CARE DECLARATION I, MARY A SMITH (the  “Declarant”),  now  residing  at  Maricopa County, State of Arizona, being of sound mind and not under or subject to duress, fraud, or undue influence, intending to create a "Pro-Life" Health Care Declaration do voluntarily state my advance instructions relating to my medical treatment and care. I strongly believe in pro-life principles and I do not agree   with   “Living   Wills”   and   other   similar   directives   biased   in   favor   of   death.     This   Health   Care Declaration is to be interpreted in favor of continued life. If I am unable to give directions regarding the use of life-sustaining treatment, it is my intention that this Health Care Declaration shall be honored by my family, physicians and care providers as the final expression of my instructions relating to my medical treatment or care. I am a competent adult who understands and accepts the consequences, purposes and effects of this document. INTENDED APPLICABILITY. The provisions of this Health Care Declaration apply to any diagnosis, whether I am in a terminal condition, a permanently unconscious state or otherwise. These provisions are effective during any period of time in which I am unable to communicate my informed consent because of illness or injury. This Health Care Declaration is valid unless revoked. GENERAL INSTRUCTIONS. Most of what I state here is general in nature since I cannot anticipate all the possible circumstances of a future illness. I direct that those caring for me avoid doing anything which is contrary to my pro-life principles and related Christian principals. If I am in a terminal condition, I ask that I be told of this so that I might prepare myself for death. I instruct each person who may treat me or care for me in illness or injury, or who otherwise may exercise or influence dominion or control over my body, that nothing shall be done or omitted to be done with the intent to cause my death. Notwithstanding any other document I may have signed, I am not to be denied food or water as long as my body is able to assimilate them. Mechanical or artificial means are to be utilized if necessary to assure me food and water. Medical treatment and care are to be provided if necessary to cure, remedy, or relieve  the  symptoms  of  my  condition.    Evaluation  of  “quality  of  life”  is  not  to  be  a  factor.    I   want to be kept clean and comfortable. Adequate efforts should be taken to relieve my pain though I do not want to be overmedicated to the point where I am unable to comprehend my situation and communicate with those around me. I understand the purpose and effect of this document and, after careful deliberation, hereby sign my name to this Health Care Declaration on this ______ day of __________________, 2012. _________________________________ MARY A SMITH P/L Living Will Page 1 (of 2) PDF/142
  • 143. NOTE: THIS "PRO-LIFE" HEALTH CARE DECLARATION SHOULD BE (1) SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE AND (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC. The Declarant who has signed this Pro-Life Living Will & Health Care Declaration consisting of two pages of which this is the second page (i) is personally known to us or has provided proof of her identity, (ii) signed or acknowledged her signature on this Declaration in our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence, (iv) has not appointed either of us as health care representative or alternative representative as provided herein, and (v) is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address - ACKNOWLEDGEMENT - STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) P/L Living Will Page 2 (of 2) PDF/143
  • 144. ~ LIVING WILL DECLARATION ~ I, HENRY J. SMITH, being a resident of Maricopa County, State of Arizona, and an adult of sound and disposing mind and memory, not acting under duress, menace, fraud or undue influence of any person, do make, publish and declare this to be my Living Will to supplement all other Wills I may execute. Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This Instrument Entirely, I request that this Living Will be used in the event that I am mentally incapacitated with a catastrophic/terminal medical condition. 1. Declaration of Intent. I realize that, when I am conscious and functioning normally with full mental facilities, I have a legal right to accept or reject medical treatment offered to me by doctors, hospitals or other medical instrumentalities. It is my intent with this Living Will to express my commitment and to designate persons (personal agents/representatives) who are legally empowered to act for me when I am unconscious or mentally incapacitated, with full authority from me to make medical decisions for me and to accept or reject medical treatment offered to me. I rely on the constitutional law and desire that this Living Will be enforced even if I am in a state of the United States which has not adopted specific statutes related to the enforcement of Living Wills. 2. Purpose. The purpose of this Living Will is to prevent my remaining assets from being used to unnecessarily prolong my life, and instead be used to benefit those of my family and/or other heirs who benefit from my worldly estate. Also, I desire to avoid the heartache extended to my loved ones, which may be caused by a prolonged illness, and I wish to avoid additional pain and suffering of myself through whatever senses remain. In the unlikely event that this instrument may not be legally binding in the jurisdiction where I may be terminally ill, then I trust that you who care for me will feel morally bound to follow its mandate. It is my decision made after careful consideration. 3. Instruction. If at any time, I should have an incurable injury, disease or illness certified to be a terminal condition, including what is determined to be a permanent vegetative state or an irreversible coma, by two (2) physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures would serve only to artificially prolong the dying process, then I direct that life-sustaining procedures be withheld or withdrawn. In such case, I direct that I be permitted to die naturally with only, but not necessarily, the administration of medication or fluids or the performance of medical procedures deemed necessary to provide me with comfortable care - but not, however, if such administration and performance prolongs my life unnaturally. NOTWITHSTANDING, in the absence of my ability to give directions regarding any use, or the termination thereof, of any medication or fluids, I give sole and unhindered discretion and power to my (appointed) Agents of my Durable Power of Attorney for Health Care to make the final decision regarding the use, or termination thereof, of any such hydration or fluids administered to my body. I have made my expression of my legal right to refuse any treatment offered to me, in such case, and I accept the consequences from such refusal. 4. Mechanics of Implementation. In order to implement this Living Will, the following must occur: My family physician, along with one other consulting physician, shall make a finding that: I am unconscious, mentally incompetent or deranged, senile, insane, or otherwise in an abnormal mental condition where I am not reasonably able to make decisions of my own; or, through an accident, a disease, a nervous system disorder or otherwise, I have acquired an irreversible condition resulting in (i) a brain that is dead, (ii) a brain that is damaged to the point where I will not be able to enjoy a reasonably normal life, (iii) a body with damaged organs or parts that will prevent me from enjoying the quality of productive life to which I am accustomed or (iv) a combination of all of these which will prevent me from enjoying the productive life of which I am accustomed. Living Will Page 1 (of 3)PDF/144
  • 145. 4.1. Notwithstanding, if my family physician is not available, then two attending physicians may concur with the consulting physician in the finding. The findings of the physicians will be written on my patient chart or on a dated piece of paper to be placed in my patient file. 4.2. Thereupon, the representative(s) I have first designated to serve per this Living Will – i.e., my HEALTH CARE POWER OF ATTORNEY AGENTS – shall concur and evidence that concurrence on the patient chart or otherwise on the dated paper with the physicians written findings. If my first designated representative or the next is not readily available, then whichever one is the most readily available shall sign an affirmation of the decision. 4.3. If my representative is not physically available, then concurrence may be affirmed by (i) two witnesses over the phone with those witnesses evidencing the consent by writing this in the patient chart or on the dated paper concerning the physicians written findings or (ii) by telegram or other means used for transmitting the written language, a copy of which shall be placed in my medical files. The findings of my doctors and the decision of my representative, once written, shall not be subject to denunciation by anyone at any later date. 5. Persons Designated To Make Decisions. I now hereby authorize the persons whom I have appointed as Agents/Attorneys-in-Fact of my Durable Power of Attorney for Health Care, which I have simultaneously executed with this Living Will, to make the decision conferred upon them by this instrument. Neither the attending physician nor the hospital is required to determine the reason for any absence of the agents I have chosen. Whichever one, if any, of my family representatives who appears is to take the responsibility of making an effort to locate the persons designated with higher priority. However, I trust any of the persons I have named as my agents to make the necessary decisions. I know that whoever makes the decisions will have made every effort to notify all the agents to obtain their concurrence and, if they cannot contact them in time or get concurrence of all parties, they have the authority to make the necessary decisions. I designate these agents also as my guardians ad litem and guardians of my person to sign all documents and bring any legal proceeding that may be necessary to exercise the power and authority vested in them by this Living Will, which includes the power to bring court proceedings for injunctive relief, damages, or other relief if necessary to carry out my wishes expressed in this Living Will without court proceedings. However, if any doctor, hospital, or other medical institution fails to carry out the instructions of my Living Will and the decisions made by my designated agents herein, then I instruct my agents to carry out my instructions and bring immediate court proceedings to enforce this Living Will. I direct that this Living Will be implemented by my designated agents and the attending doctors acting together without the necessity of consulting courts, administrative bodies or hospital committees. 6. Protection for Persons Designated and Those Assisting. As further evidence of my convictions, which have been expressed in this Living Will, I direct that the assets of my estate and my insurance be used to hold harmless from any liability the agents designated and any doctor, hospital or other medical instrumentality that assists in carrying out my instructions of the persons designated by me to do so, except those who have acted with gross negligence or willful misconduct. x________________________________ HENRY J. SMITH Living Will Page 2 (of 3)PDF/145 
  • 146. NOTE: THIS LIVING WILL DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE NOT BENEFICIARIES OF YOUR ESTATE AND PRESENT WHEN YOU SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC. ACKNOWLEDGEMENT The Declarant signing the foregoing Living Will Declaration is personally known to us or has provided proof of his identity, signed or acknowledged his signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as his health care representative, has not named either of us as a beneficiary of his estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) Living Will Page 3 (of 3) PDF/146
  • 147. ~ LIVING WILL DECLARATION ~ I, MARY A SMITH, being a resident of Maricopa County, State of Arizona, and an adult of sound and disposing mind and memory, not acting under duress, menace, fraud or undue influence of any person, do make, publish and declare this to be my Living Will to supplement all other Wills I may execute. Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This Instrument Entirely, I request that this Living Will be used in the event that I am mentally incapacitated with a catastrophic/terminal medical condition. 1. Declaration of Intent. I realize that, when I am conscious and functioning normally with full mental facilities, I have a legal right to accept or reject medical treatment offered to me by doctors, hospitals or other medical instrumentalities. It is my intent with this Living Will to express my commitment and to designate persons (personal agents/representatives) who are legally empowered to act for me when I am unconscious or mentally incapacitated, with full authority from me to make medical decisions for me and to accept or reject medical treatment offered to me. I rely on the constitutional law and desire that this Living Will be enforced even if I am in a state of the United States which has not adopted specific statutes related to the enforcement of Living Wills. 2. Purpose. The purpose of this Living Will is to prevent my remaining assets from being used to unnecessarily prolong my life, and instead be used to benefit those of my family and/or other heirs who benefit from my worldly estate. Also, I desire to avoid the heartache extended to my loved ones, which may be caused by a prolonged illness, and I wish to avoid additional pain and suffering of myself through whatever senses remain. In the unlikely event that this instrument may not be legally binding in the jurisdiction where I may be terminally ill, then I trust that you who care for me will feel morally bound to follow its mandate. It is my decision made after careful consideration. 3. Instruction. If at any time, I should have an incurable injury, disease or illness certified to be a terminal condition, including what is determined to be a permanent vegetative state or an irreversible coma, by two (2) physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures would serve only to artificially prolong the dying process, then I direct that life-sustaining procedures be withheld or withdrawn. In such case, I direct that I be permitted to die naturally with only, but not necessarily, the administration of medication or fluids or the performance of medical procedures deemed necessary to provide me with comfortable care - but not, however, if such administration and performance prolongs my life unnaturally. NOTWITHSTANDING, in the absence of my ability to give directions regarding any use, or the termination thereof, of any medication or fluids, I give sole and unhindered discretion and power to my (appointed) Agents of my Durable Power of Attorney for Health Care to make the final decision regarding the use, or termination thereof, of any such hydration or fluids administered to my body. I have made my expression of my legal right to refuse any treatment offered to me, in such case, and I accept the consequences from such refusal. 4. Mechanics of Implementation. In order to implement this Living Will, the following must occur: My family physician, along with one other consulting physician, shall make a finding that: I am unconscious, mentally incompetent or deranged, senile, insane, or otherwise in an abnormal mental condition where I am not reasonably able to make decisions of my own; or, through an accident, a disease, a nervous system disorder or otherwise, I have acquired an irreversible condition resulting in (i) a brain that is dead, (ii) a brain that is damaged to the point where I will not be able to enjoy a reasonably normal life, (iii) a body with damaged organs or parts that will prevent me from enjoying the quality of productive life to which I am accustomed or (iv) a combination of all of these which will prevent me from enjoying the productive life of which I am accustomed. Living Will Page 1 (of 3)PDF/147
  • 148. 4.1. Notwithstanding, if my family physician is not available, then two attending physicians may concur with the consulting physician in the finding. The findings of the physicians will be written on my patient chart or on a dated piece of paper to be placed in my patient file. 4.2. Thereupon, the representative(s) I have first designated to serve per this Living Will – i.e., my HEALTH CARE POWER OF ATTORNEY AGENTS – shall concur and evidence that concurrence on the patient chart or otherwise on the dated paper with the physicians written findings. If my first designated representative or the next is not readily available, then whichever one is the most readily available shall sign an affirmation of the decision. 4.3. If my representative is not physically available, then concurrence may be affirmed by (i) two witnesses over the phone with those witnesses evidencing the consent by writing this in the patient chart or on the dated paper concerning the physicians written findings or (ii) by telegram or other means used for transmitting the written language, a copy of which shall be placed in my medical files. The findings of my doctors and the decision of my representative, once written, shall not be subject to denunciation by anyone at any later date. 5. Persons Designated To Make Decisions. I now hereby authorize the persons whom I have appointed as Agents/Attorneys-in-Fact of my Durable Power of Attorney for Health Care, which I have simultaneously executed with this Living Will, to make the decision conferred upon them by this instrument. Neither the attending physician nor the hospital is required to determine the reason for any absence of the agents I have chosen. Whichever one, if any, of my family representatives who appears is to take the responsibility of making an effort to locate the persons designated with higher priority. However, I trust any of the persons I have named as my agents to make the necessary decisions. I know that whoever makes the decisions will have made every effort to notify all the agents to obtain their concurrence and, if they cannot contact them in time or get concurrence of all parties, they have the authority to make the necessary decisions. I designate these agents also as my guardians ad litem and guardians of my person to sign all documents and bring any legal proceeding that may be necessary to exercise the power and authority vested in them by this Living Will, which includes the power to bring court proceedings for injunctive relief, damages, or other relief if necessary to carry out my wishes expressed in this Living Will without court proceedings. However, if any doctor, hospital, or other medical institution fails to carry out the instructions of my Living Will and the decisions made by my designated agents herein, then I instruct my agents to carry out my instructions and bring immediate court proceedings to enforce this Living Will. I direct that this Living Will be implemented by my designated agents and the attending doctors acting together without the necessity of consulting courts, administrative bodies or hospital committees. 6. Protection for Persons Designated and Those Assisting. As further evidence of my convictions, which have been expressed in this Living Will, I direct that the assets of my estate and my insurance be used to hold harmless from any liability the agents designated and any doctor, hospital or other medical instrumentality that assists in carrying out my instructions of the persons designated by me to do so, except those who have acted with gross negligence or willful misconduct. x________________________________ MARY A SMITH Living Will Page 2 (of 3)PDF/148 
  • 149. NOTE: THIS LIVING WILL DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE NOT BENEFICIARIES OF YOUR ESTATE AND PRESENT WHEN YOU SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC. ACKNOWLEDGEMENT The Declarant signing the foregoing Living Will Declaration is personally known to us or has provided proof of her identity, signed or acknowledged her signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as her health care representative, has not named either of us as a beneficiary of her estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of ________________, 2012, before me, _____________________, the undersigned, personally appeared MARY A SMITH who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarants signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) Living Will Page 3 (of 3) PDF/149
  • 150. ~ LAST WILL & TESTAMENT ~ Introduction This ninth section contains your will. It serves as your Last Will & Testament. It automatically rescinds - makes null and void - any Last Will & Testament you may have established in the past. Without a living trust, a will functions as a legal document (primarily) for the purpose of distributing ones estate at death. With a living trust, a will serves only to convey property into the trust that had not been, for whatever reason, previously transferred to the trust. Thus, a will, when used in conjunction with a living trust, is a "Pour-over Will". In simplest terms, your Pour-over Will serves to transfer your unfunded property into your trust, at your death. The beneficiaries of your trust will ultimately inherit those assets. Realize, however, that a Pour-over Will is not a substitute for lifetime funding of your trust. The reason is that even though your unfunded property will eventually be transferred into your trust (at your death) by your Pour-over Will, it still must be probated. The Pour-over Will also provides a "post-mortem" means of transferring property bequeathed to you, had you not survived the bequest, to your trust. However, any such property received "post-mortem" would also have to go through probate. Your executor(s) will be appointed in this document as well as a guardian(s), if any, for minor children or incapacitated dependents. Your will can also be used in making a "final statement" either in the document itself or by an appendage (codicil) to the will. Your Pour-over Wills must be signed, witnessed and notarized. __________________PDF/150
  • 151. ~ LAST WILL & TESTAMENT ~ (Pour-over Will) HENRY J. SMITH I, HENRY J. SMITH, a resident of Maricopa County, State of Arizona, revoke any prior Wills and Codicils and make this my Last Will & Testament. ARTICLE ONE - Payment of Expenses & Taxes - I instruct my Personal Representative to make payments from my estate viz: 1. Except to the extent paid by United States obligations accepted by the United States Treasury Department at par in payment of federal estate taxes that are assets of the: SMITH FAMILY TRUST Dated: ______________________, 2012 and that are required to be applied by the Trustee of said Trust in payment of federal estate taxes that become due because of my death, my Personal Representative shall pay said federal estate taxes by first applying to such payment any such United States obligations that are assets of my estate. 2. My Personal Representative shall pay from the residue of my estate or shall direct the Trustee of said Trust to pay, or both, as determined in the sole discretion of my Personal Representative, the expenses of my last illness and funeral, valid debts, expenses of administering my estate, including non-probate assets, and any estate or other death taxes which become due because of my death, including any interest and penalties. 3. It is the purpose and intent of this Paragraph (and Sub-Paragraphs) that, so far as is practical, any estate taxes paid shall be paid out of my entire estate whether passing by this Will or otherwise concerning property over which I possessed a general power of appointment, before distribution to any beneficiary: 3.1. If estate (or income) tax or any part thereof is paid by, or collected out of, that part of my estate passing to or in the possession of any person other than my Personal Representative, in its capacity as Personal Representative, such person shall be entitled to reimbursement out of any part of my estate, or otherwise, still undistributed. Such reimbursements may be by a just and equitable contribution by the persons whose interest in my estate would have been reduced if the tax had been paid before distribution or whose interest is subject to equal or prior liability for the payment of taxes, debts, or other charges against my estate. LW&T Page 1 (of 5) PDF/151
  • 152. 3.2. If any part of my gross estate on which estate tax has been paid consists of the value of property included in my gross estate under IRC Section 2041, my Personal Representative shall be entitled to recover from the person (or persons, prorata if more than one recipient) receiving such property by reason of the exercise, nonexercise, or release of a power of appointment, such portion of the total tax paid as the value of such property bears to the taxable estate. 3.3. In the case of any such property received by my spouse for which a deduction is allowed under IRC Section 2056 (relating to the marital deduction), this Paragraph (and Sub- Paragraphs) shall not apply to such property except as to the value thereof reduced by an amount equal to the excess of the aggregate amount of the marital deductions allowed under Section 2056. 3.4. If any part of my gross estate consists of property which is includible in my gross estate by reason of IRC Section 2044, relating to certain property for which a marital deduction was previously allowed, my estate shall be entitled to recover from the person receiving the property the amount by which the total tax which has been paid exceeds the total tax which would have been payable if the value of such property had not been included in my gross estate. 3.5. My Personal Representative may (i) exercise all of the foregoing elections and any others available under any tax law, to obtain, to the extent practicable, both the optimum reduction in my estate taxes and in the income taxes estimated to be payable by my estate or the beneficiaries thereof, any business interests in my estate and the optimum deferral of all of those taxes, (ii) make adjustments between income and principal amounts and to allocate the benefits from any election among the various beneficiaries of my estate, and (iii) compensate for the consequences of any election that it believes has had the effect of preferring one beneficiary or a group of beneficiaries of my estate over others. All such foregoing elections and adjustments shall not, however, diminish any portion that would create an adverse taxable event to my estate or beneficiaries thereof. ARTICLE TWO - Specific Allocations - I give all of my tangible personal property and all of my realty interests and any other of my assets to the Trustee of the Trust that I created with my spouse, the: SMITH FAMILY TRUST Dated: ______________________, 2012 LW&T Page 2 (of 5)PDF/152 
  • 153. ARTICLE THREE - Estate Residue Disposition- I give the rest, residue and remainder of my estate, that may not have been transferred to said Trust during my lifetime, consisting of all the property I can dispose of by my Will and not effectively disposed of by the preceding Articles of this Will, to the Trustee of said Trust, as amended and existing at my death, in order to be added to and disposed of as a part of the assets of such Trust. ARTICLE FOUR - Personal Representative Appointment - I hereby nominate and appoint my spouse, MARY A SMITH, to serve as the Personal Representative / Executor of my Will. If my spouse is unable or unwilling to serve or continue as Executor of my Will, then I nominate HENRY J SMITH, JR to serve as my Executor. If HENRY J SMITH, JR is unable or unwilling to serve or continue as the Executor of my Will, in such case, then I nominate ANN B SMITH to serve. ARTICLE FIVE - Fiduciary Provisions - The following shall apply to my Fiduciary / Personal Representative: 1. Administrative Powers: My Personal Representative, in addition to all other powers conferred by law that are not inconsistent with those contained herein, shall have the power, exercisable without authorization of any court to (i) sell at private or public sale, to retain, to lease, and to mortgage or pledge for the purpose of borrowing money, any or all of the real or personal property of my probate estate (if any), (ii) make partial distributions from my probate estate (if any) from time to time and to distribute the residue in cash or in kind or partly in each, and for that purpose to determine the value of property distributed in kind, and (iii) sell to, buy from, lend to, and borrow from the Trustee of said Trust even though such Trustee may be the same as my Personal Representative. 2. Administrative Provisions: I direct unsupervised administration of my estate and that my probate estate (if any) be administered in as informal a manner as my Personal Representative deems advisable and as applicable law permits. No bond or other indemnity shall be required of any Personal Representative. I expressly waive any requirement that any Trust created by me be submitted to the jurisdiction of any court, or that the Trustee of such Trust(s) be appointed or confirmed, or that their accounts be heard by any court. To effect the nomination of my Personal Representative, the person possessing the nomination shall file with the court, having jurisdiction over my estate, at any time after the date of my death. If a 30-day period lapses during which no Personal Representative is acting hereunder and no nomination is filed with the court, a statement that a designated person or entity is nominated as an additional or Successor Personal Representative shall be filed, by the heirs (beneficiaries) of my estate, to effectively appoint a Successor Personal Representative on my behalf. LW&T Page 3 (of 5)PDF/153
  • 154. ARTICLE SIX - Guardianship Appointments - If a personal guardian is necessary for any minor or dependent child of mine, then I hereby nominate MARY A SMITH, my spouse, to serve as guardian of the same. If my spouse is unwilling/unable to serve as guardian, then I nominate HENRY J. SMITH, JR. to serve. ARTICLE SEVEN - Contents of Will, Testimonial and Attestation Provisions - This Last Will & Testament consists of seven (7) Articles (this Article inclusive) and four (4) pages. Following this (final) Article Seven is an unnumbered page containing a self-proving affidavit. IN WITNESS WHEREOF, I HAVE HEREUNTO SET MY HAND AND SEAL THIS ______ DAY OF ___________________, 2012. x________________________________ HENRY J. SMITH This document has been signed, sealed, published and declared by the above named Testator as his Last Will & Testament in our presence who, at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address Subscribed, sworn to and acknowledged before me this - __________ day of _____________________, 2012. NOTARY SEAL: x________________________________ Notary Public LW&T Page 4 (of 5) PDF/154
  • 155. ACKNOWLEDGEMENT I, HENRY J. SMITH, the Testator of the within, hereby certify that I executed my signature on my Will on the __________ day of _____________________, 2012. I further certify that I requested signatures as witnesses to my Last Will & Testament from the following individuals: _________________________________ (and) _________________________________ Witness Name Witness Name x________________________________ HENRY J. SMITH We, the above identified witnesses, being first duly sworn, do depose and say to the undersigned authority that we witnessed HENRY J. SMITH’S   execution of his Last Will & Testament and that he signed it willingly and that each of us, in his presence and hearing and in the presence of each other, sign herein as witnesses to his signing, and that to the best of our knowledge he is eighteen years of age or older, of sound mind, under no constraint or undue influence and competent to make testamentary disposition of real and personal property. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of _______________, 2012, before me, _____________________, the undersigned, personally appeared HENRY J. SMITH, and the above named WITNESSES, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) LW&T Page 5 (of 5) PDF/155
  • 156. ~ LAST WILL & TESTAMENT ~ (Pour-over Will) MARY A SMITH I, MARY A SMITH, a resident of Maricopa County, State of Arizona, revoke any prior Wills and Codicils and make this my Last Will & Testament. ARTICLE ONE - Payment of Expenses & Taxes - I instruct my Personal Representative to make payments from my estate viz: 1. Except to the extent paid by United States obligations accepted by the United States Treasury Department at par in payment of federal estate taxes that are assets of the: SMITH FAMILY TRUST Dated: ______________________, 2012 and that are required to be applied by the Trustee of said Trust in payment of federal estate taxes that become due because of my death, my Personal Representative shall pay said federal estate taxes by first applying to such payment any such United States obligations that are assets of my estate. 2. My Personal Representative shall pay from the residue of my estate or shall direct the Trustee of said Trust to pay, or both, as determined in the sole discretion of my Personal Representative, the expenses of my last illness and funeral, valid debts, expenses of administering my estate, including non-probate assets, and any estate or other death taxes which become due because of my death, including any interest and penalties. 3. It is the purpose and intent of this Paragraph (and Sub-Paragraphs) that, so far as is practical, any estate taxes paid shall be paid out of my entire estate whether passing by this Will or otherwise concerning property over which I possessed a general power of appointment, before distribution to any beneficiary: 3.1. If estate (or income) tax or any part thereof is paid by, or collected out of, that part of my estate passing to or in the possession of any person other than my Personal Representative, in its capacity as Personal Representative, such person shall be entitled to reimbursement out of any part of my estate, or otherwise, still undistributed. Such reimbursements may be by a just and equitable contribution by the persons whose interest in my estate would have been reduced if the tax had been paid before distribution or whose interest is subject to equal or prior liability for the payment of taxes, debts, or other charges against my estate. LW&T Page 1 (of 5) PDF/156
  • 157. 3.2. If any part of my gross estate on which estate tax has been paid consists of the value of property included in my gross estate under IRC Section 2041, my Personal Representative shall be entitled to recover from the person (or persons, prorata if more than one recipient) receiving such property by reason of the exercise, nonexercise, or release of a power of appointment, such portion of the total tax paid as the value of such property bears to the taxable estate. 3.3. In the case of any such property received by my spouse for which a deduction is allowed under IRC Section 2056 (relating to the marital deduction), this Paragraph (and Sub- Paragraphs) shall not apply to such property except as to the value thereof reduced by an amount equal to the excess of the aggregate amount of the marital deductions allowed under Section 2056. 3.4. If any part of my gross estate consists of property which is includible in my gross estate by reason of IRC Section 2044, relating to certain property for which a marital deduction was previously allowed, my estate shall be entitled to recover from the person receiving the property the amount by which the total tax which has been paid exceeds the total tax which would have been payable if the value of such property had not been included in my gross estate. 3.5. My Personal Representative may (i) exercise all of the foregoing elections and any others available under any tax law, to obtain, to the extent practicable, both the optimum reduction in my estate taxes and in the income taxes estimated to be payable by my estate or the beneficiaries thereof, any business interests in my estate and the optimum deferral of all of those taxes, (ii) make adjustments between income and principal amounts and to allocate the benefits from any election among the various beneficiaries of my estate, and (iii) compensate for the consequences of any election that it believes has had the effect of preferring one beneficiary or a group of beneficiaries of my estate over others. All such foregoing elections and adjustments shall not, however, diminish any portion that would create an adverse taxable event to my estate or beneficiaries thereof. ARTICLE TWO - Specific Allocations - I give all of my tangible personal property and all of my realty interests and any other of my assets to the Trustee of the Trust that I created with my spouse, the: SMITH FAMILY TRUST Dated: ______________________, 2012 LW&T Page 2 (of 5)PDF/157 
  • 158. ARTICLE THREE - Estate Residue Disposition- I give the rest, residue and remainder of my estate, that may not have been transferred to said Trust during my lifetime, consisting of all the property I can dispose of by my Will and not effectively disposed of by the preceding Articles of this Will, to the Trustee of said Trust, as amended and existing at my death, in order to be added to and disposed of as a part of the assets of such Trust. ARTICLE FOUR - Personal Representative / Executor Appointment - I hereby nominate and appoint my spouse, HENRY J. SMITH, to serve as the Personal Representative / Executor of my Will. If my spouse is unable or unwilling to serve or continue as Executor of my Will, then I nominate HENRY J SMITH, JR to serve as my Executor. If HENRY J SMITH, JR is unable or unwilling to serve or continue as the Executor of my Will, in such case, then I nominate ANN B SMITH to serve. ARTICLE FIVE - Fiduciary Provisions - The following shall apply to my Executor / Personal Representative: 1. Administrative Powers: My Personal Representative, in addition to all other powers conferred by law that are not inconsistent with those contained herein, shall have the power, exercisable without authorization of any court to (i) sell at private or public sale, to retain, to lease, and to mortgage or pledge for the purpose of borrowing money, any or all of the real or personal property of my probate estate (if any), (ii) make partial distributions from my probate estate (if any) from time to time and to distribute the residue in cash or in kind or partly in each, and for that purpose to determine the value of property distributed in kind, and (iii) sell to, buy from, lend to, and borrow from the Trustee of said Trust even though such Trustee may be the same as my Personal Representative. 2. Administrative Provisions: I direct unsupervised administration of my estate and that my probate estate (if any) be administered in as informal a manner as my Personal Representative deems advisable and as applicable law permits. No bond or other indemnity shall be required of any Personal Representative. I expressly waive any requirement that any Trust created by me be submitted to the jurisdiction of any court, or that the Trustee of such Trust(s) be appointed or confirmed, or that their accounts be heard by any court. To effect the nomination of my Personal Representative, the person possessing the nomination shall file with the court, having jurisdiction over my estate, at any time after the date of my death. If a 30-day period lapses during which no Personal Representative is acting hereunder and no nomination is filed with the court, a statement that a designated person or entity is nominated as an additional or Successor Personal Representative shall be filed, by the heirs (beneficiaries) of my estate, to effectively appoint a Successor Personal Representative on my behalf. LW&T Page 3 (of 5)PDF/158
  • 159. ARTICLE SIX - Guardianship Appointments - If a personal guardian is necessary for any minor or dependent child of mine, then I hereby nominate HENRY J. SMITH, my spouse, to serve as guardian of the same. If my spouse is unwilling/unable to serve as guardian, then I nominate HENRY J. SMITH, JR. to serve. ARTICLE SEVEN - Contents of Will, Testimonial and Attestation Provisions - This Last Will & Testament consists of seven (7) Articles (this Article inclusive) and four (4) pages. Following this (final) Article Seven is an unnumbered page containing a self-proving affidavit. IN WITNESS WHEREOF, I HAVE HEREUNTO SET MY HAND AND SEAL THIS ______ DAY OF ___________________, 2012. x________________________________ MARY A SMITH This document has been signed, sealed, published and declared by the above named Testator as her Last Will & Testament in our presence who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address Subscribed, sworn to and acknowledged before me this - __________ day of _____________________, 2012. NOTARY SEAL: x________________________________ Notary Public LW&T Page 4 (of 5) PDF/159
  • 160. ACKNOWLEDGEMENT I, MARY A SMITH, the Testator of the within, hereby certify that I executed my signature on my Will on the __________ day of _____________________, 2012. I further certify that I requested signatures as witnesses to my Last Will & Testament from the following individuals: _________________________________ (and) _________________________________ Witness Name Witness Name x________________________________ MARY A SMITH We, the above identified witnesses, being first duly sworn, do depose and say to the undersigned authority that we witnessed MARY A SMITH’S   execution of her Last Will & Testament and that she signed it willingly and that each of us, in her presence and hearing and in the presence of each other, sign herein as witnesses to her signing, and that to the best of our knowledge she is eighteen years of age or older, of sound mind, under no constraint or undue influence and competent to make testamentary disposition of real and personal property. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICOPA On this ______ day of _______________, 2012, before me, _____________________, the undersigned, personally appeared MARY A SMITH, and the above named WITNESSES, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to this instrument and acknowledged to me that they executed/signed the same in their authorized capacity, and that by their signatures executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) LW&T Page 5 (of 5) PDF/160
  • 161. TRUST ASSETS & CORRESPONDENCE Introduction This tenth section contains various retitlement letters needed for transferring certain assets to your trust. These documents have been designed for convenience and expediency. Just fill in the applicable account numbers, sign the letter(s) and send it to the respective transfer agents. They, in turn, will retitle those assets to your trust. The beneficiary change letters in this section are very helpful when designating your trust as the beneficiary of your insurance, annuities, qualified plans etc. A certain amount of tax planning should be incorporated when determining the proper use of these beneficiary change letters - especially when deciding on whether your trust is to be a primary or a contingent beneficiary. Also included are stock & bond powers. These may be used to transfer title of a stock or bond certificate without having to actually (locate, relocate and) sign the certificate itself. The signed stock or bond power is simply attached to the certificate, by the transfer agent, indicating title transfer. This avoids the requirement of having to mail such certificate back and forth from the transfer agent to you. Always remember to make as many photocopies as you will need for each respective format and keep the originals in your Portfolio. You should go through all of these forms so that you understand the request that you are making with each form that you send to a transfer agent. Immediately following is a 6-page GUIDELINE-TO-FUNDING which lists most all assets that could be transferred into a trust including brief instructions regarding the procedures for the funding of each such asset into your Trust. Funding documents should be copied and subsequently filled out, signed and mailed as needed. Retain all originals. _______________PDF/161
  • 162. ~ GUIDELINE TO FUNDING ~ Funding your Trust is very important. So, in addition to the instructions found in the Trustee Memorandum, we have provided the following "guideline" to help you. Because various companies and financial institutions have their own specific requirements for asset-transfers which can (and do) change from time to time, your ultimate procedures may vary from these instructions. Nevertheless, please read this instructional carefully, it will be of much assistance to you and provide the basic information you will need as the CREATOR and TRANSFEROR of your Trust. - INDEX - Page 1) Real Estate Owned by You Page 2) Real Estate Carried by You; Promissory Notes & Sales Contracts; and Limited Partnerships Page 3) General Partnerships & Proprietorships; Bank Accounts (Checking, Savings, Money Market & CDs); Safe Deposit Box; and Securities Accounts Page 4) Stocks & Bonds; Series E/EE Bonds; and Treasury Notes Page 5) Mutual Fund Accounts; Qualified Plan Accounts; and Annuities; Page 6) Life Insurance and Motor Vehicles REAL ESTATE OWNED BY YOU The easiest way to fund real estate (homes, condominiums, farmland, lots, timeshares etc.) into your Trust is by a Quit Claim Deed. A Quit Claim Deed is not a warrant or guarantee that the transferor (you) are transferring all interest that the legal description describes; you are transferring whatever interest (only) you have in the described property to your Trust. Although it is recommended to have the Deed recorded at the appropriate County Recorder/Registrar Office upon the execution of the Deed, it is not actually required until the Trustee transfers the Deed out of the Trust either by sale or conveyance to the beneficiaries of the Trust. It is best, though, to record the Deed immediately unless (for example) there is a pending sale. Although it varies from state to state and sometimes from county to county, a requirement often exists to fill out a "realty transfer" or "change of ownership" form when a Deed is recorded. These forms can be obtained from the Office of the County Recorder where the Deed is going to be recorded and should be submitted with the Deed when recorded. On occasion, an existing Deed will include a "due on sale/transfer" clause indicating that the entire note will come due upon the date of the transfer/sale of the owners interest. Although a transfer to a living trust is neither a transfer of ownership nor a sale and should not trigger the pay-up requirement, it is advisable (if your mortgage has such a clause) to check with the mortgagee before transferring such property to your Trust. GF Page 1 (of 6)PDF/162
  • 163. REAL ESTATE CARRIED BY YOU (secured) Real estate can be sold with a carry-back feature in generally two ways - by (1) a Contract for Deed and/or (2) a Deed of Trust/Trust Deed. A Contract for Deed is when the seller holds the note himself/herself and the purchaser makes installment (or other) payments directly to the seller. A Deed of Trust/Trust Deed is where a third party (i.e., a trustee) holds the note on behalf of the seller and the purchaser makes payments to that trustee. In either case, the forthcoming interest of the seller can be conveyed into a living trust by a Secured Realty Interest (SRI) document. The SRI does not necessarily have to be recorded. The purchaser/payor should, however, have possession of a copy of the SRI so that the payor knows to send the payments to the Trustee of your Trust. If you are carrying paper on a Contract for Deed then you should also "quit claim" your interest in that Deed by signing a Quit Claim Deed deeding that property into the Trust. That way, it will be in the Trust in the event that the payor defaults on the purchase payments and the Contract for Deed is never fulfilled. PROMISSORY NOTES & SALES CONTRACTS (unsecured) If you are a holder/carrier of a Promissory Note and/or a Sales Contract, you may convey your interest in the note or contract to your Trust by a Conveyance document similar to the SRI. In most cases it would not be necessary to record the conveyance document. Again, the payor of the note should have a copy of the Conveyance document so that the payor knows your interest in the Note has been transferred to your Trust and that the payor now needs make payments to the Trustee of your Trust. LIMITED PARTNERSHIP INTERESTS Limited Partnership Interests can be transferred to a trust by either the transfer agent of the limited partnership changing title of the owners limited partnership interest - from the owner to the Trustee of the owners Trust or by a Conveyance of Limited Partnership Interest document. The conveyance document method is usually sufficient (a copy of the conveyance document should be sent to the transfer agent of the partnership) if the transfer agent understands the conveyance. If the limited partnership interest takes the form of a "registered security" then the transfer agent should be contacted. Often times, "registered" limited partnerships have cumbersome restrictions or requirements concerning transfers   of   its   partner’s   interests;;   thus,   the   process   can   be   expensive. In such case, dont use the retitlement method - use the conveyance document method. GF Page 2 (of 6)PDF/163
  • 164. GENERAL PARTNERSHIP INTERESTS & SOLE PROPRIETORSHIPS Interests in a general partnership and a sole proprietorship are similar in structure and can be transferred to a trust by a Conveyance document. This conveyance document should describe the name, type and location of the business. For a partnership, the State of domicile and the date partnership was established should be on the conveyance document. These documents generally do not need to be recorded. BANK ACCOUNTS (Checking, Savings, Money Market & CDs) As a rule, most banks will accept a copy of the Certificate of Trust (COT) along with the appropriate Request For Retitlement (RFR) Letter to change title of your accounts; usually, only pages 1 & 5 of the COT is all that is required to send. It is not necessary to have new checks printed reflecting the name of the Trust or Trustees unless you wish to have it that way. It is best to hand-carry the RFRs to the bank as you will need to sign the signature cards for the title change. If you have someone (such as a child) as a "signer" on the existing joint account, then request a "disclaimer form" from the bank so as to have the signer disclaim interest in the account. The (signed) disclaimer form, RFR and the COT will then need to be presented to the banks transfer agent to take the joint name off of the account and a new signature card will need to be signed by you. If the bank does not have a disclaimer card method to get the joint signers name off of the account then you will have to close the account and open a new account in the name of the Trust. SAFETY DEPOSIT BOXES Generally, the same procedures apply as defined in the funding of Bank Accounts (see above). SECURITIES ACCOUNTS (in general) Each individual security account can be retitled using the RFR letter. If you have many different securities accounts, you may consider consolidating all of the accounts (stocks, bonds, mutual funds etc.) into one brokerage/security account (i.e. - "street name" account), before retitling into your Trust. Thus you need to retitle only one account (into your Trust) and it gives you the added convenience of receiving only one (consolidated) monthly report. This procedure will also help simplify the administration of your Trust at a later date. In addition, if you withdraw from the accounts, all the assets will likely already be titled to your Trust even if out of the account. GF Page 3 (of 6)PDF/164
  • 165. STOCKS & BONDS If you are personally holding stock and/or bond certificates, again it is recommended (but not required) that you consolidate them into one brokerage account. To do that you will need to sign a stock/bond power which also needs to be signed by a Signature Guarantor (bank official or other person authorized under the Securities & Exchange Commission). It is not recommended to sign the actual certificate itself (unless required by a transfer agent); rather, sign only the stock/bond power and attach it to the appropriate certificate(s). Then, send the powers and COT (and certificates) by registered mail to the transfer agent of the broker/dealer for retitlement. You will likely be required to sign a "Letter of Authorization" to transfer stocks or bonds to your Trust. It will be provided, in such case, by the transfer agent where you will need to sign, fill out and send back with the stock/bond powers and certificates. Depending on the efficiency of the transfer agent, it may be 4-6 weeks before this whole transaction is completed. If you do not consolidate your stock and/or bond certificates into a brokerage account then you must either sign over the certificate itself to the Trustee of your Trust or sign a stock/bond power to the Trustee of your Trust for each certificate and attach the power to the certificate. SERIES E/EE BONDS The transfer of Series E/EE bonds requires that Treasury Form #PD 1851 (Request to Reissue in Trustee Name) needs to be completed listing all of the Bonds in chronological order (of issue dates) with respective serial numbers and current registrations. These forms can usually be obtained at your local bank or the nearest Federal Reserve Bank - Office/Branch (or call 1-800-333-2919 to request forms). Send a copies of pages 1 & 5 of the COT along with these forms (signature guaranteed) to the nearest Federal Reserve Bank, or: Federal Reserve Bank Securities Department P.O. Box 419440 Kansas City, MO 64141 When mailing to the Fed, copy the bonds for your records and mail certified. The reissue and return of bonds will take approximately 60 days. TREASURY NOTES Treasury Form #PD5178 (Transaction Request) needs to be completed by listing the notes on the form. If you have a "statement" of ownership then identify the bonds from the list on the statement. Mail, along with copies of the COT, as per the above instructions concerning Treasury Bonds. GF Page 4 (of 6)PDF/165
  • 166. MUTUAL FUND ACCOUNTS You will need to submit a RFR form for each Mutual Fund that you are transferring to your Trust. Many Mutual Fund companies now require the transferors signature to be guaranteed on the RFR; if so, you can usually get this done at your bank or your brokers office. When mailing the RFR(s), send along with a copy of the COT (pages 1 & 5). QUALIFIED PLAN ACCOUNTS (IRAs & Pension Plans) It is not necessary to transfer title of a qualified plan account (and not advisable, for income tax purposes); it is only necessary to make the Trust the contingent (or primary) beneficiary. This is so because such accounts usually have a POD (Payable on Death) provision wherein the payee will receive the account funds outright and without probate. Use the appropriate - Request for Contingent Beneficiary (RFCB) - form if you wish to have your spouse (or another person) receive such funds outright if he/she survives you. Thus if your spouse (or other payee) does not survive you then the funds will go to your Trust at your death and avoid probate; it may be left in trust until the time the decedent (if living) would have been 70 & 1/2 years. When your spouse is the contingent beneficiary and he/she survives you then he/she may "rollover" your qualified account, at your death, into his/her own qualified account (if done within 60 days) without incurring a taxable event. Use the appropriate - Request for Primary Beneficiary (RFPB) - form if you wish to have your Trust receive such funds at your death regardless of who survives you. As a married couple, this method may have a beneficial tax planning function as it relates to your A/B Trust format and if you have a relatively large estate. The reason is that if your Trust is the primary beneficiary of such funds then the funds could be divided into a split interest between Trust A & Trust B at the first spouses death; this may be preferred as to just having the surviving spouse receive the entire qualified plan account if the surviving spouses estate were to exceed the value sheltered by the Unified Credit against transfer taxes. Check with your financial advisor and/or tax counsel for more help, if needed. ANNUITIES Generally, annuities should not be transferred to your Trust - only payable to your Trust at your death. Depending on the type of estate planning you are doing and the type of annuity product you have, either a primary or contingent beneficiary designation (to your Trust) could be appropriate (RFPB or RFCB form). If you wish to transfer title of your annuity to your Trust (RFR), be certain that an unwanted taxable event will not result before you make such a transfer. GF Page 5 (of 6)PDF/166
  • 167. LIFE INSURANCE Generally, life insurance is not to be transferred to your Trust - only payable to your Trust at your death. Depending on the type of estate planning you are doing and the type of insurance product and amount of death benefit (relative to your estate size) you have, either a primary or contingent beneficiary designation (to your Trust) could be appropriate (RFPB or RFCB form). If, however, you wish to transfer title of your life insurance to your Trust for whatever reason, be certain that an unwanted income taxable event will not be the result. MOTOR VEHICLES Although the Assignment of Tangible Personal Property form will suffice to transfer motor vehicles into your Trust, it may be more convenient (for administration of your Trust at your death) to retitle your motor vehicles into your Trust. This is done by contacting your local Department of Motor Vehicles. A nominal fee may be charged to process the title but no taxable event will occur. If you do retitle, make sure to let your insurer (of the motor vehicle) know what you are doing in transferring the motor vehicle to your Trust. Also remember, when you subsequently purchase a motor vehicle, you can purchase it as Trustees thus automatically funding the vehicle into your Trust without any further transaction required. GF Page 6 (of 6)PDF/167
  • 168. ~ JOINT REQUEST FOR ASSET RETITLEMENT ~ From: M/M Henry J. Smith Date:___________________________ 28 Wilson St Phoenix, AZ 8501 To: ____________________________________ ____________________________________ ____________________________________ Dear Sirs/Madams: We, the undersigned, a married couple, as Settlors/Trustees, have established a Revocable Living Trust referred to as – SMITH FAMILY TRUST Dated: ______________________, 2012 Enclosed is a copy of the Certificate of Trust concerning (and as verification of) such trust agreement. We wish to transfer title of our assets (currently in our name as joint owners), held on account with your firm, to ourselves as trustees (to wit) – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 As per Treasury Regs -- 1.671-4(b), 1.6012-3(a)(9) & 301.6109-1(a)(2) -- it is not necessary for a grantor to establish a separate tax ID number for a revocable living trust provided the grantor is serving as trustee. Therefore, income from this trust will be 1040 income until further notice. Listed below are, according to our records, products and corresponding account numbers identifying our assets currently being held on account with your firm which are to be transferred and retitled as stated above: Type of Asset Account Number ______________________________________/______________________________________ ______________________________________/______________________________________ ______________________________________/______________________________________ Please mail any documents that are necessary to fill out and sign to accomplish this transfer. We wish to complete this transaction as soon as possible. Sincerely, x________________________________ x________________________________ HENRY J. SMITH MARY A SMITHPDF/168
  • 169. ~ SOLE REQUEST FOR RETITLEMENT ~ From: HENRY J. SMITH Date:___________________________ 28 Wilson St Phoenix, AZ 8501 To: ____________________________________ ____________________________________ ____________________________________ Dear Sirs/Madams: I have, with my spouse, established a Revocable Living Trust referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 Enclosed is a copy of the Certificate of Trust concerning (and as verification of) such trust agreement. I wish to transfer title of my assets (currently in my name alone), held on account with your firm, to the trustees of said trust (to wit) – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 As per Treasury Regs -- 1.671-4(b), 1.6012-3(a)(9) & 301.6109-1(a)(2) -- it is not necessary for a grantor to establish a separate tax ID number for a revocable living trust provided the grantor is serving as trustee. Therefore, income from this trust will be 1040 income until further notice. Listed below are, according to my records, products and corresponding account numbers identifying my assets currently being held on account with your firm which are to be transferred and retitled as stated above: Type of Asset Account Number ______________________________________/______________________________________ ______________________________________/______________________________________ ______________________________________/______________________________________ Please mail any documents that are necessary to fill out and sign to accomplish this transfer. I wish to complete this transaction as soon as possible. Sincerely, x____________________________________ HENRY J. SMITHPDF/169
  • 170. ~ SOLE REQUEST FOR RETITLEMENT ~ From: MARY A SMITH Date:___________________________ 28 Wilson St Phoenix, AZ 8501 To: ____________________________________ ____________________________________ ____________________________________ Dear Sirs/Madams: I have, with my spouse, established a Revocable Living Trust referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 Enclosed is a copy of the Certificate of Trust concerning (and as verification of) such trust agreement. I wish to transfer title of my assets (currently in my name alone), held on account with your firm, to the trustees of said trust (to wit) – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 As per Treasury Regs -- 1.671-4(b), 1.6012-3(a)(9) & 301.6109-1(a)(2) -- it is not necessary for a grantor to establish a separate tax ID number for a revocable living trust provided the grantor is serving as trustee. Therefore, income from this trust will be 1040 income until further notice. Listed below are, according to my records, products and corresponding account numbers identifying my assets currently being held on account with your firm which are to be transferred and retitled as stated above: Type of Asset Account Number ______________________________________/______________________________________ ______________________________________/______________________________________ ______________________________________/______________________________________ Please mail any documents that are necessary to fill out and sign to accomplish this transfer. I wish to complete this transaction as soon as possible. Sincerely, x____________________________________ MARY A SMITHPDF/170
  • 171. ~ SOLE REQUEST FOR NEW BENEFICIARY APPOINTMENT ~ From: HENRY J. SMITH Date:___________________________ 28 Wilson St Phoenix, AZ 8501 To: ____________________________________ ____________________________________ ____________________________________ Dear Sirs/Madams: I have, with my spouse, established a Revocable Living Trust referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 Enclosed is a copy of the Certificate of Trust concerning (and as verification of) such trust agreement. I wish to designate the trustees of said trust (to wit) – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 as the PRIMARY BENEFICIARY of a certain account(s) currently on account with your company and thereby revoking the previous beneficiary appointment. Listed below are, according to my records, products and corresponding account numbers identifying my assets currently being held on account with your firm concerning this new appointment: Type of Asset Account Number ______________________________________/______________________________________ ______________________________________/______________________________________ ______________________________________/______________________________________ Please mail any documents that are necessary to fill out and sign to accomplish this new beneficiary appointment. I wish to complete this change as soon as possible. Sincerely, x____________________________________ HENRY J. SMITHPDF/171
  • 172. ~ SOLE REQUEST FOR NEW BENEFICIARY APPOINTMENT ~ From: MARY A SMITH Date:___________________________ 28 Wilson St Phoenix, AZ 8501 To: ____________________________________ ____________________________________ ____________________________________ Dear Sirs/Madams: I have, with my spouse, established a Revocable Living Trust referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 Enclosed is a copy of the Certificate of Trust concerning (and as verification of) such trust agreement. I wish to designate the trustees of said trust (to wit) – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 as the PRIMARY BENEFICIARY of a certain account(s) with your company and thereby revoking the previous beneficiary appointment. Listed below are, according to my records, products and corresponding account numbers identifying my assets currently being held on account with your firm concerning this new appointment: Type of Asset Account Number ______________________________________/______________________________________ ______________________________________/______________________________________ ______________________________________/______________________________________ Please mail any documents that are necessary to fill out and sign to accomplish this new beneficiary appointment. I wish to complete this change as soon as possible. Sincerely, x____________________________________ MARY A SMITHPDF/172
  • 173. ~ SOLE REQUEST FOR CONTINGENT BENEFICIARY ~ From: HENRY J. SMITH Date:___________________________ 28 Wilson St Phoenix, AZ 8501 To: ____________________________________ ____________________________________ ____________________________________ Dear Sirs/Madams: I have, with my spouse, established a Revocable Living Trust referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 Enclosed is a copy of the Certificate of Trust concerning (and as verification of) such trust agreement. I wish to designate the trustees of said trust (to wit) – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 as the CONTINGENT BENEFICIARY of a certain account(s) of mine with your company and thereby revoking the previous beneficiary appointment. Listed below are, according to my records, products and corresponding account numbers identifying my assets currently being held on account with your firm concerning this new appointment: Type of Asset Account Number ______________________________________/______________________________________ ______________________________________/______________________________________ ______________________________________/______________________________________ Please mail any documents that are necessary to fill out and sign to accomplish this new beneficiary appointment. I wish to complete this change as soon as possible. Sincerely, x____________________________________ HENRY J. SMITHPDF/173
  • 174. ~ SOLE REQUEST FOR CONTINGENT BENEFICIARY ~ From: MARY A SMITH Date:___________________________ 28 Wilson St Phoenix, AZ 8501 To: ____________________________________ ____________________________________ ____________________________________ Dear Sirs/Madams: I have, with my spouse, established a Revocable Living Trust referred to as the: SMITH FAMILY TRUST Dated: ______________________, 2012 Enclosed is a copy of the Certificate of Trust concerning (and as verification of) such trust agreement. I wish to designate the trustees of said trust (to wit) – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 as the CONTINGENT BENEFICIARY of a certain account(s) of mine currently with your company and thereby revoking the previous beneficiary appointment. Listed below are, according to my records, products and corresponding account numbers identifying my assets currently being held on account with your firm concerning this new appointment: Type of Asset Account Number ______________________________________/______________________________________ ______________________________________/______________________________________ ______________________________________/______________________________________ Please mail any documents that are necessary to fill out and sign to accomplish this new beneficiary appointment. I wish to complete this change as soon as possible. Sincerely, x____________________________________ MARY A SMITHPDF/174
  • 175. ~ JOINT IRREVOCABLE STOCK POWER ~ FOR VALUE RECEIVED, the undersigned – HENRY J. SMITH & MARY A SMITH (a married couple) HENRY J. SMITH SSN# ______________ / MARY A SMITH SSN# ______________ hereby sell, assign and transfer to – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 ______________ shares of (COMMON OR PREFERRED) ___________________________ stock of (NAME OF CORPORATION) _____________________________________________ represented by Certificate No. ________________________ inclusive, standing in the name of the undersigned on the books of said Corporation. The undersigned hereby (and irrevocably) appoint – __________________________________________ (TRANSFER AGENT) as attorney-in-fact to transfer said stock, on the books of said Corporation, with full power of substitution in the premises. Dated this ______ day of _________________, ________. x___________________________________ x________________________________ HENRY J. SMITH MARY A SMITH IMPORTANT – READ CAREFULLY SIGNATURES GUARANTEED The signatures to the Power must correspond with the names as written upon the face of the certificates in every case without alternation or enlargement or any change whatever. SIGNATURE GUARANTEE should be made by a member or member organization of the New York Stock Exchange, members of other Exchanges having signatures on file with the transfer agent or by a commercial bank or trust company having its principal office or correspondent in New York CityPDF/175
  • 176. ~ JOINT IRREVOCABLE BOND POWER ~ FOR VALUE RECEIVED, the undersigned – HENRY J. SMITH & MARY A SMITH (a married couple) HENRY J. SMITH SSN: _____________ / MARY A SMITH SSN: _____________ hereby sell, assign and transfer to – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 ____________ bonds of (name of corporation) ______________________________________ in the principal amount of $__________, No._________________________ inclusive, standing in the name of the undersigned on the books of said Corporation. The undersigned hereby (and irrevocably) appoint – __________________________________________ (TRANSFER AGENT) as attorney-in-fact to transfer said bond(s), on the books of said Corporation, with full power of substitution in the premises. Dated this ______ day of _________________, ________. x___________________________________ x________________________________ HENRY J. SMITH MARY A SMITH IMPORTANT – READ CAREFULLY SIGNATURES GUARANTEED The signatures to the Power must correspond with the names as written upon the face of the certificates in every case without alternation or enlargement or any change whatever. SIGNATURE GUARANTEE should be made by a member or member organization of the New York Stock Exchange, members of other Exchanges having signatures on file with the transfer agent or by a commercial bank or trust company having its principal office or correspondent in New York CityPDF/176
  • 177. ~ SOLE IRREVOCABLE STOCK/BOND POWER ~ FOR VALUE RECEIVED, the undersigned – HENRY J. SMITH (a married person) Social Security # __________________ hereby sells, assigns and transfers to – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 ____________ stocks/bonds of (name of corporation) _____________________________________ in the principal amount of $__________, No._________________________ inclusive, standing in the name of the undersigned on the books of said Corporation. The undersigned hereby (and irrevocably) appoints – __________________________________________ (TRANSFER AGENT) as attorney-in-fact to transfer said bond(s), on the books of said Corporation, with full power of substitution in the premises. Dated this ______ day of _________________, ________. x________________________________ HENRY J. SMITH IMPORTANT – READ CAREFULLY SIGNATURES GUARANTEED The signatures to the Power must correspond with the names as written upon the face of the certificates in every case without alternation or enlargement or any change whatever. SIGNATURE GUARANTEE should be made by a member or member organization of the New York Stock Exchange, members of other Exchanges having signatures on file with the transfer agent or by a commercial bank or trust company having its principal office or correspondent in New York CityPDF/177
  • 178. ~ SOLE IRREVOCABLE STOCK/BOND POWER ~ FOR VALUE RECEIVED, the undersigned – MARY A SMITH (a married person) Social Security # __________________ hereby sells, assigns and transfers to – HENRY J. SMITH & MARY A SMITH, Trustees SMITH FAMILY TRUST Dated: ______________________, 2012 ____________ stocks/bonds of (name of corporation) _____________________________________ in the principal amount of $__________, No._________________________ inclusive, standing in the name of the undersigned on the books of said Corporation. The undersigned hereby (and irrevocably) appoints – __________________________________________ (TRANSFER AGENT) as attorney-in-fact to transfer said bond(s), on the books of said Corporation, with full power of substitution in the premises. Dated this ______ day of _________________, ________. x________________________________ MARY A SMITH IMPORTANT – READ CAREFULLY SIGNATURES GUARANTEED The signatures to the Power must correspond with the names as written upon the face of the certificates in every case without alternation or enlargement or any change whatever. SIGNATURE GUARANTEE should be made by a member or member organization of the New York Stock Exchange, members of other Exchanges having signatures on file with the transfer agent or by a commercial bank or trust company having its principal office or correspondent in New York CityPDF/178