Fill and Sign the Blocked Account 497430014 Form

Superior Court of Washington County of In the Guardianship of: _______________________________, Incapacitated Person 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 Incapacitated Person) ________________________________________ . The deposit was made into Account No. (last four digits) __________________________ . The undersigned, financial institution agrees to hold this account and any subsequent 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. This receipt is binding on all successors, transferees, assignees, agents and employees of the undersigned financial institution. I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signed at (city) ________________________, (state) __________ on (date) _____________________. __________________________________ ____________________________________________ Signature Print Name and Title ___________________________________ ____________________________________________ Name of Bank/Financial Institution Telephone/Fax Number ____________________________________ ____________________________________________ City, State, Zip Code Email Address Receipt of Funds into Blocked Account (RCP) - Page 1 of 1 WPF GDN 04.0600 (01/2009)