Certification By Trustee Of Qualified Blind Trust
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1Form 40
CERTIFICATION BY TRUSTEE OF
QUALIFIED BLIND TRUST
I,
_____________________________________________
(name
of
trustee),
the trustee of a trust executed on _______________________,
20 ______,
and
named
or
identifi ed
as
the
________________________________
(name
of
trust),
by
_________________________________
(name
of
public offi cer), a public offi cer within the State of Florida who holds the offi ce of
_________________________________________________(name
of
offi ce
held),
hereby certify that the trust meets all of the requirements of Section 112.31425, Florida
Statutes, as enacted by Chapter 2013-36, Section 5, Laws of Florida.
___________________________________________________
(Status of trustee--bank, trust company, other institutional fi duciary,
attorney, certifi ed pubic accountant, broker, or investment advisor)
________________________________________________________
(Date this certication made)
________________________________________________________
(Signature of person making certifi cation)
________________________________________________________
(Printed name of person signing)
Person signing is
individual trustee
OR
agent for institutional fi duciary
CE FORM 40 - EFF. 10/2013
Adopted by reference in Rule 34-7.010(1)(j), F.A.C.
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