IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS ESTATE OF ) ) ) ) _____________________________________________ ) ) Case No. ________________________ CERTIFICATE OF DEPOSITORY - RECEIPT To the Probate Court of Lake County, Illinois: The undersigned hereby acknowledges that _____________________________________________________________ Guardian or Personnel Representative of the Estate of ____________________________________________________________________________________ Name of Ward or Decedent has deposited in the ________________________________________________________________________________ Name of Institution the sum of ________________________________________________________________________________________ titled in the name of ________________________________________________________________________________ Guardian/Representative for the Estate of Ward/Decedent in Account Number _________________________. It is being understood that the same is to be held on deposit, in trust, with no withdrawals or distributions until further order of the Probate Court of Lake County, Illinois. ______________________________________ Name of Institution Date: ___________________________, 20____ By: ______________________________________ Its: Authorized Representative ______________________________________ Print Name Signed and sworn to before me this ______ day of ____________________, 20____, _______________________________________ Notary Public 171P-209 (Rev. 12/11) American LegalNet, Inc. www.FormsWorkFlow.com