STATE OF RHODE ISLANDCounty ofEstate ofAlias FILED DATEFORCOURT USE ONLY PROBATE COURT OF THECity or Town ofNo. I/We, the undersigned, as Principal(s):NameStreet AddressCity/TownState Zip CodeEmailPhone NumberNameStreet AddressCity/TownState Zip CodeEmailPhone NumberDate of execution, that if the above bonded principal, the duly appointed (check one) To the best of my knowledge or belief, the statement(s) contained within this document are truthful and accurate.Signatureof FiduciaryDateSignature of FiduciaryDateWitness NameSignatureDateWitness NameSignatureDate UNIVERSAL APPOINTMENT BOND (Corporate Surety Exempted) RIGL 33-17-1.2 & RIGL 33-17-1.3PC-3.1A (Rev. 09/17) State of Rhode Island and Providence PlantationsProbate CourtPage 1 of 1 Executor AdministratorGuardianOther FIDUCIARY SIGN HERE SIGN HERESIGN HERE American LegalNet, Inc. www.FormsWorkFlow.com