MARK J. BARTOLOTTA, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO IN THE MATTER OF _____________________________________________________________ CASE NO. _____________________ VERIFICATION OF RECEIPT AND DEPOSIT Pursuant to Court order, the sum of $______________________ was deposited with _______________________ on the ______ day of __________________, ______, as evidenced by Savings/Certificate of Deposit Account Number _______________________. This account is held soley in the name of _____________________________, a minor. By accepting said deposit for said minor, this institution agrees that said deposit, together with accumulated interest, shall held and no part thereof released until minor attains the age of majority or upon further order of this Court. _________________________ Financial Institution By_________________________ Authorized Officer _________________________ Typed or Printed Name _________________________ Phone Number _________________________ Date FORM 22.3 ­ VERIFICATION OF RECEIPT AND DEPOSIT American LegalNet, Inc. www.FormsWorkFlow.com