IN THE CIRCUIT COURT FOR FLORIDA IN RE: ESTATE OF File No. Deceased. Division COUNTY, PROBATE DIVISION RECEIPT (With Refunding Language) The undersigned, having an interest in this estate as ______, hereby acknowledges having received from the personal representative of this estate the following: , A condition of this distribution is the agreement by the undersigned to return to the personal representative, upon demand, any property improperly received and its income since distribution or, if the undersigned does not have the property, to return to the personal representative the value of the property at the date of disposition and its income and gain received. The undersigned shall have no obligation to return the property unless it was improperly distributed. Signed on this ________ day of _________________________, ________. Name [Print or Type Names Under All Signature Lines] Bar Form No. P-5.0511 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com