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MS DOM LTC Income Trust Document

EP&P/Appendix A-8-1

Revised July 2017

___________________________________ Settlor STATE OF _________________

COUNTY OF _______________

Personally appeared before me, the undersigned authority in and for said county and state, on the ______ day of ______, 20___, within my jurisdiction, the within named ____________________, who acknowledged that (he) (she) executed the above and foregoing instrument. ___________________________ (NOTARY PUBLIC) MY COMMISSION EXPIRES: STATE OF _________________

COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for said county and state, on the _____day of __________, 20___, within my jurisdiction, the within named ________________, who acknowledged that (he) (she) (they) executed the above and foregoing instrument.

____________________________ (NOTARY PUBLIC)

MY COMMISSION

TRUSTEE INFORMATION:

NAME: ____________________ SSN: ____________________

TELEPHONE NUMBER: ____________________

ADDRESS: ________________________________

________________________________

RELATIONSHIP TO SETTLOR: ____________________

(Rev 6/08)