Michigan Compiled Laws, Chapter 487. Financial Institutions § 487.715

1.

Name of financial institution:

2.

Nature of Account:

Check

________ Savings Account;

________ Commercial Account;

________ Certificate of Deposit;

________ Other Credits (describe):

3.

Name and address of person designated as A:

4.

Name and address of person designated as B:

5.

Who may withdraw funds during lifetime of A and B:

5.

Check

________ A; ________ B; ________ Either A or B;

________ Signatures of both A and B.

6.

Who may revoke this contract by written notice to the financial

institution:

Check

________ A; ________ B; ________ Either A or B;

________ Signatures of both A and B. In the event of revocation, the right to withdraw funds shall be determined by designation of ownership in item 7.

7.

Who owns the funds during the lifetime of A and B:

Check

________ A; ________ B; ________ Equally by A and B;

Other proportions (describe):  ________

8.

Who owns the funds and has the right to withdraw if A dies first:

Check

________ B; ________ A's estate; ________ Equally by B and A's estate;

Other proportions (describe): ________.

9.

Who owns the funds and has the right to withdraw if B dies first:

Check

________ A; ________ B's estate; ________ Equally by A and B's estate;

Other proportions (describe):  ________.

10.

If A and B should die simultaneously without proof of who survives, which

provision shall control:

Check ________ Item 8 above; ________ Item 9 above.

11.

Signature of persons having right of withdrawal: ________.

12.

Date of signature: ________.