Receipt

SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ _________ _________ _________ _________ ADM INT IDD GDN TRP _________ _________ _________ _________ _________ Estate of _____________________________________ Minor/Ward/Deceased RECEIPT I, the undersigned, _______________________________________ hereby (insert name) acknowledge to have received from ________________________________, (insert name) (personal representative/conservator/guardian/trustee), of the estate of _____________________________________________ assets consisting of ___________________________________________________________ as shown by the approved ___________________ account in said cause on _______________, 20______. _______________________________________ Signature of filer _______________________________________ Typed name of filer _______________________________________ Address (actual address/not Post Office Box) _______________________________________ _______________________________________ March 2014 ­ 814.10.v2 American LegalNet, Inc. www.FormsWorkFlow.com _______________________________________ Telephone number _______________________________________ Email address _______________________________________ Unified Bar number (if filer is an attorney) March 2014 ­ 814.10.v2 American LegalNet, Inc. www.FormsWorkFlow.com