Receipt {NHJB-2139-P}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) RECEIPT 1. RECEIVED FROM Executor Administrator Special Administrator , serving as: Ancillary Executor or Administrator Administrator With Will Annexed Guardian 2. Conservator Administrator De Bonis Non Trustee The amount of money and/or personal property at inventory value: $ , in full partial satisfaction of the following: Distribution(s) according to terms of trust Distributive share upon termination of trust Balance upon termination of guardianship Balance upon termination of conservatorship Distributive share of decedent's estate Residuary share under decedent's will Money bequeathed under decedent's will Personal property bequeathed under decedent's will (specify) Other (specify) Date Recipient Print Name of Recipient NHJB-2139-P (03/11/2011) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com