Receipt Of Funds Into Blocked Financial Account

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 The undersigned, financial institution agrees to hold this account and any subsequent 19 20 21 22 23 24 25 26 deposits to the account and not to allow any withdrawals of the funds or securities from the institution, except under Order of this Court. However, the institution may move the funds into different accounts, securities or investment vehicles without prior court order, provided the proceeds are not released from the control of the institution as a part of the transfer or transaction. /// /// /// An Incapacitated Person. IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KING In the Minor Settlement of: ____________________, ) ) ) ) ) ) ) Case No.: RECEIPT OF FUNDS INTO BLOCKED FINANCIAL ACCOUNT (RCP) RECEIPT is hereby acknowledged of $____________________, deposited with the undersigned by _________________, who is the [ ] Guardian, [ ] Guardian ad Litem, or [ ]Attorney for ______________________________(name of Minor Beneficiary or Petitioner). The deposit was made into Account No. ______________________(Last four digits). RECEIPT OF FUNDS INTO BLOCKED ACCOUNT - 1 12/2005 REVISED GUARDIANSHIP FORMS American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 This receipt is binding on all successors, transferees, assignees, agents and employees of the undersigned financial institution. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. Signed at ________________, Washington, ___________, ____200__. Signature Name of Bank/Financial Institution City, State, Zip Code Printed Name and Title Telephone/Fax Number Email Address RECEIPT OF FUNDS INTO BLOCKED ACCOUNT - 2 12/2005 REVISED GUARDIANSHIP FORMS American LegalNet, Inc. www.FormsWorkFlow.com