SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF _______________________________ ______________________________________________X In the Matter of the Guardianship of ______________________________________________ RELEASE SETTLING ACCOUNTS File No. ________________________ A Former Infant. ______________________________________________X TO THE SURROGATE’S COURT OF THE COUNTY OF_________________________________ : WHEREAS, ______________________________________________________________ of (Name of Guardian) __________________________________________________________, State of_____________________, (Permanent Address) was duly appointed guardian of the (person and) property of ______________________________________, an infant, on___________________ ,_______, by the Surrogate’s Court of __________________________, County, and thereupon duly qualified as guardian; and __________________________________________ WHEREAS, the former infant attained the age of eighteen on ______________________ ,_______ ; and WHEREAS, the guardian has settled with the former infant all matters relating to the guardianship and to the property of the former infant, in which settlement the guardian is charged: With amount of personal property and income thereof received With amount of income from infant’s real estate received Total $ __________________________ $ __________________________ $ __________________________ And is credited: With amount expended in care of infant With amount applied to support, maintenance and education of infant $ __________________________ $ __________________________ Total $ __________________________ Leaving a Balance of $ __________________________ -1­ American LegalNet, Inc. www.FormsWorkFlow.com NOW, THEREFORE, in consideration of the payment and delivery to me, _____________________________________________of _______________________________________ , (Name of Former Infant) (Permanent Address) $ ________ in cash and property, the receipt of which is hereby acknowledged, being the balance in the hands of the guardian and also in consideration of a mutual agreement to waive a judicial accounting, I do for myself, my executors and administrators, release and forever discharge ____________________________________ (Name of Guardian) and ______________________________________________________________________________________________________ (Name of Depositories) Clerk of the Court, Guardianship Clerk of the Court, from any and every claim, demand, action and cause of action, account, liability or reckoning of every name and nature for and on account of any and every matter and thing whatsoever arising from or in any manner relating to or connected with my estate and guardianship. IN WITNESS WHEREOF, we, the guardian and former infant, have set our hands and seals this day of_______________________, ___________________ . Signature of Guardian Signature of Former Infant Print Name Print Name On this ____________ day of ___________________ , ________________ ,before me personally came __________________________________ and ________________________________________________ known to me to be the individual(s) described in and who executed the foregoing instrument. Such person (s) duly swore to such instrument before me and duly acknowledged that he/she/they executed the same. Notary Public Commission Expires: _________________________ (Affix Notary Stamp or Seal) Signature of Attorney: _____________________________________________________________________ Print Name: ________________________________________________ Firm Name: __________________________________ Tel. No.: ________________________________ Address of Attorney: ____________________________________________________________________ -2­ American LegalNet, Inc. www.FormsWorkFlow.com