Fill and Sign the Receipt for Restricted Funds Form

Name:_________________________________________________Address:_______________________________________________City, State. Zip:_________________________________________Telephone:_____________________________________________State Bar Code:_________________________________________Client:_________________________________________________ IN THE SUPERIOR COURT OF THE STATE OF ARIZONA In and for the County of ___________________ ___________________________________________IN THE MATTER OF: CASE NO. RECEIPT FOR RESTRICTED FUNDS BY FORMER WARD[ ] A Minor Protected Person [ ] An Adult Incapacitated Person _________________________________________________________________________________PB5TER MNotice 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, ____________________________________ have received funds from in my restricted account(s) and the funds have been released in accordance with the Order of the Court Releasing Funds dated _________________________I have received all the funds held in the conservatorship to which I am entitled, as follows:A. Amount received: $_______________________ ____B.Date received: ________________________ ____C.Name of financial institution that held the funds: ___________________________________________ ________________________________________Signature of Former Ward STATE OF ARIZONA ) )ss COUNTY OF __________________) The above receipt was signed before me this _____ day of _____________________________, 199 ______by _______________________________________Notary Public ______________________________ ___________(Seal)