Estate Receipt Form

ESTATE RECEIPT FORM

This Estate Receipt Form is made and entered into on by and between Estate Representative: in the capacity of of the Estate of (Decedent), Probate Court: , Case No. (collectively, "Estate Representative"), and Recipient: , Address: ("Recipient").

RECITALS

WHEREAS, Decedent died on leaving assets subject to probate administration; and

WHEREAS, the Estate Representative has been appointed by the probate court and is authorized to collect, manage, and distribute the assets of the Estate in accordance with the Decedent's will and applicable law; and

WHEREAS, Recipient has agreed to accept certain assets of the Estate described below in full or partial satisfaction of Recipient's distribution, share, claim, or consideration as specified herein.

NOW THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the sufficiency of which is hereby acknowledged, the parties agree as follows:

1. RECEIPT AND ACKNOWLEDGMENT

The Estate Representative hereby delivers, transfers and conveys to Recipient, and Recipient hereby acknowledges receipt of, the assets described in Schedule A attached hereto and incorporated by reference (the "Assets"). Recipient acknowledges that delivery of the Assets constitutes actual physical or constructive receipt sufficient to transfer possession and title as of the Effective Date.

2. DESCRIPTION OF ASSETS (SCHEDULE A)

Cash/checks/securities Real property Tangible personal property Receivables/other

3. CONSIDERATION

Recipient accepts the Assets in full satisfaction of the distribution, claim or consideration described as: . Recipient acknowledges that no further distribution shall be required from the Estate with respect to the Assets covered by this Receipt, except as provided herein.

4. REPRESENTATIONS AND WARRANTIES

The Estate Representative represents and warrants to Recipient that: (a) the Estate Representative has been duly appointed and is authorized to make distributions of Estate assets; (b) to the best of the Estate Representative's knowledge, the Assets described in Schedule A constitute property of the Estate subject to administration; and (c) no other transfer of the Assets described in Schedule A has been made that would materially impair the Recipient's receipt of title or possession, except as otherwise disclosed in writing to Recipient prior to the Effective Date.

Recipient represents and warrants that Recipient has inspected the Assets (to the extent reasonably practicable), accepts them in their current condition, and understands that, except for the foregoing express representations and warranties, the Assets are conveyed AS IS and WHERE IS, with no further warranty, express or implied, except as required by law.

5. RELEASE AND FINAL ACCOUNTING

Upon execution of this Receipt, Recipient releases and forever discharges the Estate Representative and the Estate from any and all claims, demands, causes of action, liabilities, and obligations arising out of or related to the Assets described in Schedule A through the Effective Date, including but not limited to claims for additional distributions, accounting, or losses relating to the delivered Assets, except for claims arising from the Estate Representative's willful misconduct or gross negligence.

6. INDEMNIFICATION

Recipient agrees to indemnify and hold harmless the Estate Representative and the Estate from and against any and all losses, damages, liabilities, costs and expenses (including reasonable attorneys' fees) arising from Recipient's possession, use, or disposition of the Assets after the Effective Date, except to the extent such losses result directly from the Estate Representative's willful misconduct or gross negligence.

7. NOTICES

All notices required or permitted under this Receipt shall be in writing and shall be delivered personally or sent by certified mail, return receipt requested, to the addresses set forth below or to such other address as a party designates by written notice:

8. AMENDMENT; WAIVER; COUNTERPARTS

This Receipt may be amended only by a written instrument signed by both parties. No waiver of any provision of this Receipt shall be effective unless in writing and signed by the party against whom enforcement is sought. This Receipt may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

9. GOVERNING LAW

This Receipt shall be governed by and construed in accordance with the substantive laws of the state of without regard to its conflicts of law principles.

10. ENTIRE AGREEMENT; SEVERABILITY

This Receipt constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and negotiations, whether written or oral. If any provision of this Receipt is held invalid or unenforceable, the remainder of this Receipt shall remain in full force and effect to the maximum extent permitted by law.

11. AUTHORITY TO EXECUTE

Each person signing below represents and warrants that he or she is duly authorized to execute and deliver this Receipt on behalf of the party for which he or she signs and that the execution and delivery of this Receipt constitutes a valid and binding obligation of such party.

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