PROBATE COURT OF SHELBY COUNTY, OHIO TRUST OF GUARDIANSHIP OF CASE NO. VERIFICATION OF RECEIPT AND DEPOSIT [For use in Custodial Account] Pursuant to Court order, the sum of Dollars ($ the day of ) was deposited with , on as evidenced by Certificate of Whereas, the fiduciary has Deposit/Savings Account No. presented the assets for such deposit together with a certified copy of the Entry of said order. WHEREFORE, the undersigned hereby acknowledges the deposit and/or receipt of the assets and agrees to hold the same subject to the further orders of the court. By accepting said deposit for said minor, said institution agrees that said deposit is to be held and no part thereof released until said minor attains the age of majority, unless otherwise ordered by this court. Financial Institution Signature of Authorized Officer Typed or Printed Name Date American LegalNet, Inc. www.FormsWorkFlow.com H.C. FORM 204.07 - VERIFICATION OF RECEIPT AND DEPOSIT OF CUSTODIAL ACCOUNT 02/10/03