IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT IN AND FOR PINELLAS COUNTY, FLORIDA PROBATE DIVISION REF #: - - GD - Section IN RE: The GUARDIANSHIP of ACCEPTANCE OF DESIGNATION AS RESTRICTED DE POSITORY OF ASSETS (Investment Powers) I, , an authorized officer of , a dealer as defined in Section 517.021(6) Florida Statutes, who is a member of the Security Investment Protection Corporation, doing business in this state, or a Florida Statutes, hereby agree to accept the designation as depository of assets of , the above - named Ward, described as; AND THE BELOW INFORMATION IS REQUIRED Account # Account Type Balance: and will hold and disburse said assets pursuant to Section 69.031, Florida Statutes; provided, however, that the depository shall incur no liability in connection with this acceptance until it has filed with the Court its duly executed receipt for such assets . The financial institution shall not allow any withdrawal or disbursement of funds without a court order. NAME: TITLE: DATE: American LegalNet, Inc. www.FormsWorkFlow.com