(Top 3 inches reserved for recording data) CERTIFICATE OF CUSTODIANSHIP by Individual Minn. Stat. 507.49 State of Minnesota, County of Minnesota Uniform Conveyancing Blanks Form 90.2.1 (2016) , being first duly sworn on oath states, or affirms under penalties of perjury, that: 1. The name of the custodianship, if one is given, is: 2. The date of the custodianship instrument is: 3. The name of each owner of property held in the custodianship is: (if none, so indicate) . . 4. The name of each original custodian is: 5. The name and address of each custodian empowered to act under the custodianship instrument at the time of execution of this Certificate of Custodianship is: 6. The custodians are authorized by the instrument to sell, convey, pledge, mortgage, lease, or transfer title to any interest in real or personal property, except as limited by the following: (if none, so indicate) 7. Any other custodianship provisions the custodians or owners of property held in the custodianship include: Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 90.2.1 8. The custodianship instrument has has not been terminated or revoked. (check one box) The statements contained in this Certificate of Custodianship are true and correct and there are no other provisions in the custodianship instrument, or amendments to it, that limit the powers of the custodianship to sell, convey, pledge, mortgage, lease, or transfer title to interests in real or personal property. Custodian or Property Owner (signature) Signed and sworn to (or affirmed) before me on (month/day/year) (insert name of Custodian or Property Owner making statement) , by . (Stamp) (signature of notarial officer) Title (and Rank): My commission expires: (month/day/year) THIS INSTRUMENT WAS DRAFTED BY: (insert name and address) American LegalNet, Inc. www.FormsWorkFlow.com