IN THE CIRCUIT COURT FOR FLORIDA IN RE: GUARDIANSHIP OF COUNTY, PROBATE DIVISION File No. Division CERTIFICATION BY DEPOSITORY as an authorized officer or representative of accepts appointment as depository of the assets of the Ward, certifies that the depository is doing business in the State of Florida and is a financial institution described in Florida Statutes Section 69.031, or is a dealer as defined in Section 517.021(6)(a), and a member of the Security Investment Protection Corporation. As depository it will hold and disburse said assets pursuant to Florida Statutes Section 69.031; provided, however, that the depository will incur no liability in connection with this acceptance until it has filed with the court its duly executed receipt for the assets. Signed on this day of , . , (Depository) By: (Title) [Print or Type Names Under All Signature Lines] Bar Form No. G-4.082 © Florida Lawyers Support Services, Inc. Revised January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com