Fill and Sign the Access Safe Deposit 497426810 Form

PERMISSION FOR DEPUTY/AGENT TO ACCESS SAFE DEPOSIT BOX IN WITNESS THEREOF, I,       hereby appoint       as “deputy” or “agent” to the safe deposit box located at       in the city of       in the state of       and grant permission for said deputy or agent to access my safe deposit box in the following circumstances only:       By granting permission to access the aforementioned safe deposit box, no power of attorney is being created, and this permission to access is revocable at will. This grant of permission should not be construed as transferring any additional rights in the contents thereof. This is a means of permitting the aforementioned deputy or agent to access said box in the aforementioned circumstances only. ____________________       Signature Date ___________________ Signature of “Deputy” ______________________ County I, ______________, a ________________, in and for said county in said state, hereby certify that _____________, whose name is signed to the foregoing conveyance, and who is known to me, acknowledged before me on this day that, being informed of the conveyance, he/she executed the same voluntarily on the same day the same bears date. Given under my hand this the ____ day of ____________, ____. _________________________________ NOTARY PUBLIC Print Name: _______________________ My Commission Expires: ______________________