Affidavit Of Existence Of Trust Form (Page 2 of 2) in pdf

6. Choose one from the following:



The trust instrument has not been terminated, revoked, modified or amended in any manner

which would cause the representations herein to be incorrect.



The trust instrument has not been terminated, revoked, modified or amended in any manner

however, the proper legal name of the Trust is



The trust instrument has been modified or amended.

As a result of these amendments, the

current name of the Trust is

7. This Affidavit is made upon the representations of the trustee/trustees and the statements contained

in this Affidavit are true and correct and that there are no other provisions in the trust instrument or

amendments to it that limit the powers of the trustee/trustees.

8. I/We understand that Great-West Life & Annuity Insurance Company of New York is not responsible

for ensuring the validity of the trust or for carrying out the terms of the trust in any way. It is the sole

responsibility of the trustee to certify the validity of the trust and to administer the funds in a manner

consistent with the trustee’s powers.

9. In the event that a third party institutes legal action asserting a claim or cause of action

compromised by this Affidavit, then, and in that event, the Affiant/Affiants, each hereby agrees to

indemnify, hold harmless and defend Great-West Life & Annuity Insurance Company of New York

against such claim or cause of action.

Each undersigned hereby affirms that (s)he accepted the appointment of a Trustee of the above-named

Trust and is acting under appointment of a Trustee and assumed the fiduciary and other legal

responsibilities of a Trustee.

Trustee Signature

_______________________________________________ DATE________________________________________

Trustee Name (Please Print)

Trustee Signature

_______________________________________________ DATE________________________________________

Trustee Name (Please Print)

State of ___________________________)

County of _____________________________)

This instrument was acknowledged before me on ______________, 20__ by __________________________________,

proved to me on the basis of satisfactory evidence to be the person who appeared before me.

My commission expires:

Notary Public______________________

Great-West Life & Annuity Insurance Company of New York

Administrative Service Ofﬁce

PO Box 174392

Denver, CO 80217-4392

AFFIDAVIT OF TRUST

03/01/2016

Page 2 of 2

Affidavit Of Existence Of Trust Form Page 2