FOR CLERK’S USE ONLY Name of Person Filing: ________________________________________ Mailing Address: ________________________________________ City, State, Zip Code: ________________________________________ Day/Evening Telephone: ________________________________________ Attorney Bar Number (if applicable) ___________________________________ Self (Without a Lawyer) or Representing: Attorney for ________________________________________ SUPERIOR COURT OF ARIZONA MOHAVE COUNTY In the Matter of (Check one or both) Guardianship Conservatorship of Case Number: ________________________ ________________________________ an Adult RECEIPT OF RESTRICTED FUNDS BY A FORMER PROTECTED OR INCAPACITATED PERSON NOTICE TO CONSERVATOR: Mail or deliver this signed and notarized receipt to Clerk of Superior Court 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 adult. 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: Name of financial institution(s) that held the funds Date Received Amount TOTAL AMOUNT RECEIVED: OATH OR AFFIRMATION STATE OF ARIZONA County of Mohave ) ) ss. I swear or affirm that the contents of this document are true and correct to the best of my knowledge and belief, under penalty of perjury. ______________________________________ Signature of former Protected Person Date: ____________________ Sworn to or affirmed before me this ____________ day of _____________, 20_____ by ____________________________________________ My Commission Expires:_______________________ 03/7/2011 _____________________________________ Notary Public / Deputy Clerk Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com