AGENT APPOINTMENT BY NONRESIDENT FIDUCIARY (SS-4512)
                                                                                   For Office Use Only
                                     Business Services Division
                              Tre Hargett, Secretary of State
                                     State of Tennessee
                                     312 Rosa L. Parks Ave., 6th Fl.
                                         Nashville, TN 37243
                                         (615) 741-2286
                                         Filing Fee $10.00

 The undersigned, a nonresident person, bank or trust company, wishing to act as a fiduciary in the State of 
 Tennessee in conformity with the laws thereof, hereby appoints the Secretary of State of the State of Tennessee 
 as the undersigned’s agent for service of process pursuant to T.C.A. § 35-50-107.

 All process in any suit or proceeding against the undersigned may be served upon the Tennessee Secretary 
 of State in any action or proceeding relating to any trust, estate or matter within this State in respect of which 
 the undersigned is acting in a fiduciary capacity. 

 The undersigned agrees that any process against the undersigned, which is served upon the Tennessee 
 Secretary of State, shall be of the same legal force and validity as if served on the undersigned.

 It is understood that this appointment shall continue for as long as any liability shall remain outstanding against 
 the undersigned pertaining to any such matters.

1. The specific trust, estate or person for which the undersigned has been appointed as fiduciary is:
    
2. The street address (including zip code) of the undersigned (to which all copies of legal process should be 
   addressed) is:
 Address:    

 City:                                     State:                     Zip Code:    

 Note: Pursuant to T.C.A. §10-7-503, all information on this form is public record.

Executed this  ______ day of             , 20 ___.

Name (Printed or Typed)

Signature

(Rev: 6/13)                                                                                          RDA 1764