Name of Donor / Settler:

Gender of Donor / Settler (circle one):

 Male / Female

Date of Birth of Donor (DD/MM/YYYY):

Amount Settled:

Date Settled (DD/MM/YYYY):

Duration of Trust (circle one):

Single Life Only  /  Joint Life

If Joint Life is selected, please provide:

Name of Joint Life:

Gender of Joint Life (circle one):

Male / Female

Date of Birth of Joint Life (DD/MM/YYYY):

Initial Account Set-Up Fee, if any ($):

Capital Distribution Fee, if any (%):

This request is made by:

Organization:

Contact Person:

Telephone Number:

Fax Number:

Email Address:

Signature of Contact Person:

Date of Request (DD/MM/YYYY):

Report Deadline* (DD/MM/YYYY):