Fiduciary Services Application

FIDUCIARY SERVICES APPLICATION

Recitals

WHEREAS, Applicant seeks to engage Fiduciary to provide fiduciary, trustee and related services described herein and to perform all duties consistent with the standards of care applicable to fiduciaries under applicable law; and

WHEREAS, Fiduciary represents that it is duly qualified and authorized to perform fiduciary services, that it maintains professional indemnity insurance and appropriate licensing where required, and that it will accept appointment subject to the terms and conditions set forth in this Application and any subsequent Fiduciary Services Agreement executed by the parties.

WHEREAS, this Application will be incorporated into and form part of any Fiduciary Services Agreement executed between Applicant and Fiduciary and will be relied upon by Fiduciary in establishing its duties, powers and compensation.

Applicant Information

Individual Corporation Trust Estate Other:

Proposed Fiduciary / Service Provider

Scope of Work

Describe the fiduciary duties, assets, accounts and specific services requested. Include the scope of discretionary authority, reporting expectations and any limitations on powers.

Powers and Authorities Requested

Select powers to be conferred upon Fiduciary and specify any restrictions.

Manage, invest and reinvest assets Make distributions to beneficiaries Hire investment managers and allocate investments Prepare and file tax returns Other:

Payment Terms

Fiduciary compensation will be as follows. Applicant acknowledges responsibility for agreed fees and expenses; Fiduciary will provide periodic invoices and may require a retainer.

Monthly Quarterly Annual Fixed fee per engagement

Term and Termination

This engagement begins on and, unless earlier terminated in accordance with this Application or a subsequently executed Fiduciary Services Agreement, will continue until .

Either party may terminate this engagement for any reason upon written notice to the other party delivered at least days prior to the effective termination date. Termination does not relieve Applicant of liability for accrued fees, expenses and reasonable wind-down costs.

Confidentiality

Fiduciary shall keep confidential all nonpublic information concerning the Applicant and the assets under administration and shall not disclose such information except (a) as necessary to perform fiduciary duties, (b) as required by law, regulation or court order, or (c) as otherwise authorized in writing by Applicant. Fiduciary will employ reasonable safeguards to protect confidential information and will return or destroy confidential records upon termination subject to retention required by law or professional obligations.

Background, Disclosures and Conflict of Interest

Has the Applicant or proposed Fiduciary been subject to any criminal conviction, regulatory sanction, professional disciplinary action, or material civil judgment within the past ten (10) years?

Yes No

Are there any known conflicts of interest that would impair the Fiduciary's ability to act impartially?

Yes No

References

Authorization and Certification

By signing below, Applicant certifies that the information provided in this Application is true, complete and correct to the best of Applicant's knowledge. Applicant authorizes Fiduciary to obtain such background information, credit reports, asset records and other third-party information as Fiduciary reasonably determines necessary to accept or administer the engagement. Applicant further authorizes third parties to release such information to Fiduciary.

Applicant acknowledges that submission of this Application does not create a fiduciary relationship until such time as a Fiduciary Services Agreement is accepted and executed by both parties. Applicant agrees to reimburse Fiduciary for reasonable costs incurred in reliance on this Application if the engagement is declined or terminated for cause.

Governing Law; Entire Agreement

This Application and any subsequently executed Fiduciary Services Agreement shall be governed by and construed in accordance with the laws of the state specified by the parties in the final agreement. This Application, together with any executed Fiduciary Services Agreement, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations and understandings, whether written or oral.

Additional Terms and Notices

Applicant understands that Fiduciary will act under applicable fiduciary standards of care and will exercise discretion consistent with the powers conferred in this Application and any subsequent agreement. Applicant further understands that Fiduciary may delegate ministerial tasks to qualified third parties but will retain ultimate responsibility for oversight unless specifically agreed otherwise in writing.

Applicant authorizes Fiduciary to commence reasonable onboarding activities upon receipt of this completed Application and any required retainer. Applicant acknowledges that onboarding activities may result in charges which will be disclosed and billed in accordance with the Payment Terms above.

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