[Fill in the spaces next to the instructions. Other spaces are for Court use.]At a(an) lAS/Special Term Part of the Supreme Court of the Stateof New York, held in and for theCounty of Nassau, at the Courthouse thereof, located at100 Supreme Court Drive,Mineola, New York on the dayof 20PRESENT: HON.Justice of the Supreme Court----------------------------------------------------------------------------x[39. Index No. & Year] ,Index No. [40. Fill in name(s)] Plaintiff(s) / ORDER FOR-against-WITHDRAWAL OF ANINFANT222S FUNDS ,[41. Fill in name(s)] Defendant(s)-----------------------------------------------------------------------------x Upon the Petition of [42.Your Name] duly sworn on [43. Insert date petition signed] , and the acknowledged consent of the infant [44. Insert infant name] [45. Insert infant age] age and upon all supporting papers attached thereto, andsufficient reason appearing for the granting of the relief sought by the petitioner herein, Now on the motion of [46.Your Name] petitioner, it is ORDERED, that the [47. Insert Name of Bank] Bank, located at [48. Insert address of Bank] ,be and it is hereby authorized and directed to page over to [49. Your Name] in account number [50. Insert Number] to the credit of [51. Insert infant name] , on service upon [52. Insert Name of Bank] , of a signed copy of this American LegalNet, Inc. www.FormsWorkFlow.com order, with official raised Court Seal, the sum of [53. Insert amount]$ in a check(s) made payable to for the use and benefit of said infant.ORDERED, that receipts for any of the approved purchases shall be filed with theClerk of the Court (the Nassau County Clerk) within 90 days of the date of entry of thisorder.ENTER JSC American LegalNet, Inc. www.FormsWorkFlow.com PRESENT: HON.Justice of the Supreme Court----------------------------------------------------------------------------x , [39. Index No. & Year]Index No. / ORDER FOR [40. Fill in name(s)] -against- WITHDRAWAL OF ANINFANT222S FUNDS ,Defendant(s) -----------------------------------------------------------------------------xUpon the Petition of acknowledged consent of the infant age or the granting of the relief sought by the petitioner herein,Now on the motion of ORDERED,thatthe American LegalNet, Inc. www.FormsWorkFlow.com ORDERED, that receipts for any of the approved purchases shall be filed with theClerk of the Court (the Nassau County Clerk) within 90 days of the date of entry of thisorder.ENTER JSC American LegalNet, Inc. www.FormsWorkFlow.com