THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) RECEIPT 1. RECEIVED FROM Executor , serving as: Administrator Ancillary Executor or Administrator Administrator With Will Annexed Administrator De Bonis Non Guardian 2. Special Administrator Trustee Conservator The sum of money, personal property at inventory value thereof, amounting to $ , in full partial satisfaction of the following: Distribution(s) according to terms of trust Distributive share upon termination of trust Balance upon termination of guardianship Balance upon termination of conservatorship Distributive share of decedent's estate Residuary share under decedent's will Money bequeathed under decedent's will Personal property bequeathed under decedent's will Other (specify) Date Recipient Print Name of Recipient NHJB-2139-P (10/01/2006) (formerly AOC 136-003) Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com