COMBINED CORPORATE VERIFICATION, CONSENT AND DESIGNATION For use when petitioner to be appointed is a bank or trust company STATE OF COUNTY OF The undersigned, a Title ss.: of Name of Bank or Trust Company a corporation duly qualified to act in a fiduciary capacity without further security, being duly sworn, says: 1. VERIFICATION: I have read the foregoing petition subscribed by me and know the contents thereof, and the same is true of my own knowledge, except as to the matters therein stated to be alleged upon information and belief, and as to those matters I believe it to be true. 2. CONSENT: I consent to accept the appointment as ANCILLARY ADMINISTRATOR ANCILLARY ADMINISTRATOR d.b.n of the decedent described in the foregoing petition and consent to act as such fiduciary. 3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the Surrogate s Court of County, and his or her successor in office as a person on whom service of any process issuing from such Surrogate s Court may be made, in like manner and with like effect as if it were served personally upon me, whenever I cannot be found within the State of New York after due diligence used. Name of Corporate Petitioner By Signature Print Name Title , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument, and that such individual made such appearance before the undersigned in , . Sworn to before me this day of On Notary Public Commission Expires: (Affix Notary Stamp or Seal) Signature of Attorney Print Name of Attorney Firm Telephone Address NYSBA's Surrogate's Court Form AA-1 (2/06) © 2006 Matthew Bender & Co., a member of the LexisNexis Group.