Receipt {E-521}

File No. STATE OF NORTH CAROLINA In The General Court Of Justice Superior Court Division County Before the Clerk IN THE MATTER OF THE ESTATE OF: Name Of Decedent/Trust RECEIPT Name Of Personal Representative/Trustee PARTIAL FINAL ACKNOWLEDGMENT I, the undersigned beneficiary, agree that I did receive from the Personal Representative/Trustee of the estate/trust a distribution consisting of the following: DESCRIPTION VALUEDate Name Of Beneficiary (Type Or Print) Signature Name Of Witness (Type Or Print) Signature AOC-E-521, New 2/01 2001 Administrative Office of the Courts