STATE OF MINNESOTA DISTRICT COURT COUNTY OF HENNEPIN FOURTH JUDICIAL DISTRICT ____________________________________ Plaintiff/Petitioner Case No. _____________________ RECEIPT OF MINOR SETTLEMENT ORDER AND FUNDS vs ____________________________________ Defendant/Respondent (Form 145.1 Provided Pursuant to Rule 145 of the Minnesota General Rules of Practice) 1. _____________________________ (“Financial Institution”) acknowledges receipt of the sum of $ ______________ on behalf of _______________________________ in this action. 2. Financial Institution acknowledges receipt of the Order Approving Settlement and For Deposit into Restricted Account dated _________________ in this action, and that the funds delivered remain subject to that order in the account specified below: Name of Depository: __________________________________ Branch Name: __________________________________ Branch Address: __________________________________ __________________________________ Account Number: __________________________________ Date Account Opened: __________________________________ Current Balance: $_________________________________ 3. This account is a federally insured, restricted account, and no withdrawal of either principal or interest shall be allowed by Financial Institution without a signed court order in this case. Dated: _____________ Type or Print Name _______________________________ Signature: _______________________________________ Title: ___________________________________________ Receipt Minor Settlement Funds/Order Last Revised 1/6/03 American LegalNet, Inc. www.FormsWorkflow.com