IN THE CHANCERY COURT OF MADISON COUNTY, MISSISSIPPI

IN RE _______________________________________	CAUSE NO.:_____________

CERTIFICATE OF FIDUCIARY - CONSERVATOR

I, fiduciary in this cause, have hereby read, understand and agree to the following:

1.	I understand that I, as fiduciary, am required to protect and preserve the funds owned by the Ward, who is the person over whom I have charge.

2.	I understand that I am required to provide notice of the order of appointment to the ward, and to all interested parties entitled to notice, within 14 days of the Court's entry of the order, and will file a Certificate of Compliance with the Court.

3.	I understand that, unless waived by the Court, I am required to submit to the Court a Conservator's Plan and an inventory within 90 days of the entry of the Order of appointment.

4.	I will not use any funds or make expenditures of the Ward's funds without prior Court approval.

5.	I agree and understand that I must consult with my attorney on any questionable expenditure prior to making said expenditure in order to gain appropriate legal advice and court approval regarding those transactions.

6.	I understand that unless waived by the Court in advance, I will be required to submit formal, annual reports on the plan and accountings to the Court.

7.	My current address and phone numbers are as follows, and I understand that in the event this information changes, I must provide that information in writing to the Clerk of this Court. Further, I understand that I am required to inform the Court of any change in the Ward's dwelling or address.

ADDRESS:_______________________________________________________

CITY, STATE, ZIP:_________________________________________________

PHONE NO.:______________________________________________________

EMAIL ADDRESS:_________________________________________________

8.	I have discussed with my attorney the duties and responsibilities required of my office as fiduciary and as set forth in this document, and I hereby agree to be bound by them.

9.	I understand that the Court can and will find me in contempt if it is proven that I have violated any of my fiduciary duties and/or this Court's order(s) and that appropriate sanctions will be levied by the Court for any violations.

10.	By acceptance of this appointment, I understand that I submit myself to the personal jurisdiction of the Court in any proceeding relating to this guardianship.

Respectfully Submitted,

__________________________________

FIDUCIARY

SWORN ACKNOWLEDGMENT

STATE OF MISSISSIPPI

COUNTY OF _____________

This day personally appeared before me, the undersigned authority at law in and for the jurisdiction aforesaid, the within named , who having been by me first duly sworn, states on oath that the matters and facts set forth in the above Certificate of Fiduciary - Conservator are true and correct as therein stated.

FIDUCIARY

SWORN TO AND SUBSCRIBED BEFORE ME, this the day of , 20___.

NOTARY PUBLIC

MY COMMISSION EXPIRES: