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(street address, city, county, state, zip code), hereinafter called the Grantor, and (Name of Trustee) of (street address, city, county, state, zip code), hereinafter called the Trustee. Whereas, Grantor is a (Name of Public Office); and Whereas, Grantor desires to avoid any conflict of interest, or appearance of any such conflict, which may arise from his duties and powers in such office and any other office to which he may subs.

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