Receipt Of Restricted Funds By Former Protected Person {PBGCD91f}

Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Licensed Fiduciary Number: ____________________________________ Representing Self, without a Lawyer or Attorney for Petitioner OR FOR CLERK'S USE ONLY Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY In the Matter of (check one or both) Guardianship Conservatorship of Case Number PB: A Minor RECEIPT OF RESTRICTED FUNDS BY A FORMER MINOR Notice to Conservator: Mail this signed and notarized receipt to Probate Court Administration within 30 days from the date of the Court Order releasing funds. Also mail this form to all parties who have appeared in the case, and to the former minor. I acknowledge that the funds in my restricted account(s) have been released in accordance with the Order of the Court releasing the funds. I have received all the funds held in the conservatorship to which I am entitled, as follows: A. Amount received: $ B. Date received: ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED PBGCD91f-042916 American LegalNet, Inc. www.FormsWorkFlow.com REC Page 1 of 2 Case No.:_____________________ C. Name of financial institution that held the funds: Signature of Former Minor STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: (date) . by (notary seal) Deputy Clerk or Notary Public ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED PBGCD91f-042916 American LegalNet, Inc. www.FormsWorkFlow.com REC Page 2 of 2