Page 3

Page 3 of 3

MS DOM HCBS Income Trust Document

EP&P/Appendix A-9-1

Revised July 2017

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 EXPIRES:

TRUSTEE INFORMATION: NAME: ____________________ SSN: ____________________ TELEPHONE NUMBER: ____________________ ADDRESS: ________________________________ ________________________________ RELATIONSHIP TO SETTLOR: ____________________