PC-EGT-22.3A (Rev. 1-2008) PROBATE COURT OF FRANKLIN COUNTY, OHIO JUDGE ERIC BROWN ROBERT G. MONTGOMERY, JUDGE ESTATE OF GUARDIANSHIP OF TRUST OF CASE NO. INCOMPETENT , DECEASED VERIFICATION OF RECEIPT AND/OR DEPOSIT OF CUSTODIAN The Probate Court of Franklin County, Ohio, on the day of , , by entry has ordered the Fiduciary to deposit with the custodial depository named below the following assets: NAME (Last four digits only) ACCOUNT NO. AMOUNT DEPOSITED TYPE OF ACCOUNT (C.D., Savings) XXXXX __ __ __ __ XXXXX __ __ __ __ XXXXX __ __ __ __ XXXXX __ __ __ __ The fiduciary has presented the assets for deposit together with a certified copy of the entry. Wherefore, the undersigned acknowledges the deposit and/or receipt of the assets described above and agrees to hold the same subject to further orders of the Court. By accepting the above assets, this institution agrees to hold all instruments verifying the deposits (certificates of deposit or savings products, etc.) and not to release any funds from these assets unless ordered in accordance with a certified copy of an Entry issued by the Probate Court. The account cannot have check writing or debit card privileges. This custodial depository will file a statement of activity annually in accordance with Local Rule 67.4 and 75.3 of the Probate Court. EXPLANATION OF ACTION TAKEN (New balances, accounts closed with account numbers (last four digits only), etc.) Custodial Depository Authorized Officer Typed or Printed Name Date RETURN TO: CUSTODIAL DESK, FRANKLIN COUNTY PROBATE COURT, 373 SOUTH HIGH STREET, 22ND FLOOR COLUMBUS, OHIO 43215-6311 FRANKLIN COUNTY FORM 22.3A - VERIFICATION OF RECEIPT AND/OR DEPOSIT OF CUSTODIAN American LegalNet, Inc. www.FormsWorkFlow.com