CIV402 State ENG Rev 5/16www.mncourts.gov/formsPage 1 of 1State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: Plaintiff/Petitioner (first, middle, last) Defendant/Respondent (first, middle, last)vs./andReceipt of Minor Settlement Order and Funds (Form 145.1) 1.("Financial Institution") acknowledges receipt of the sum of on behalf ofin this action. 2. Financial Institution acknowledges receipt of the Order Approving Settlement and For Deposit Into Restricted Account datedin 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: (Place on separate form 11.1* or only include last 4 digits) Date Account Opened: Current Balance: 3. This account is a federally insured, restricted account, and no withdrawal of either principal or interest should be allowed on Financial Institution without a signed court order in this case.I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116. Signature Dated: Name: Title:*= As required by Rule 11.2 of the Minnesota General Rules of Practice American LegalNet, Inc. www.FormsWorkFlow.com