Form 8855 - Election To Treat A Qualified Revocable Trust As Part Of An Estate Page 2

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Form 8855 (1-2009)

Page

Part III

Qualified Revocable Trust Information

Name of trust

Employer identification number (see instructions)

Name of trustee

Number, street, and room or suite no. (or P.O. box number if mail is not delivered to street address)

City or town, state, and ZIP code (if a foreign address, see instructions)

Under penalties of perjury, I, as trustee of the above-named trust:

Confirm that under applicable local law or the governing instrument, I have the authority to make this election for the trust and to agree to the

conditions of the election;

Elect the treatment provided under section 645 for this trust;

Agree to timely provide the executor (or filing trustee if there is no executor) with all the trust information necessary to permit the executor (or

filing trustee, if applicable) to file a complete, accurate, and timely Form 1041 (or Form 1040-NR for a foreign estate) for the combined electing

trust(s) and the related estate, if any, for each tax year during the election period;

Confirm that an agreement has been reached with the trustees of each QRT joining in the election, and the executor of the related estate, if

any, to allocate the tax burden of the combined electing trust(s) and related estate, if any, for each tax year during the election period in a

manner that reasonably reflects each entity’s tax obligation;

Agree to ensure that this trust’s share of the tax obligations of the combined electing trust(s) and related estate, if any, is timely paid to the

United States Treasury;

Confirm that if a filing trustee (and not an executor for a related estate) has completed Part I of this Form 8855, the trustee that completed

Part I has been appointed the filing trustee, and to the best of my knowledge and belief, an executor has not been appointed to administer a

related estate and one will not be appointed;

Agree that if a filing trustee (and not an executor for a related estate) has completed Part I of this Form 8855 and an executor is appointed

for the related estate after this Form 8855 is filed, that I will complete and file an amended Form 8855 if the later appointed executor agrees to

the election, and I agree to cooperate with the executor in filing any amended returns required to be filed as a result of the executor’s

appointment; and

Confirm to the best of my knowledge and belief, that all information of the electing trust contained in this election and any accompanying

statements or schedules is true, correct, and complete.

Signature of trustee

Date