PROBATE COURT OF SHELBY COUNTY, OHIO IN THE MATTER OF CASE NO. VERIFICATION OF RECEIPT AND DEPOSIT [Not for use in Custodial Account] Pursuant to Court order, the sum of $ on the day of as evidenced by Savings/Certificate of Deposit Account Number was deposited with , This account is held solely in the name of Security Number is By accepting said deposit for said minor, this institution agrees that said deposit, together with accumulated interest, shall be held and no part thereof released until said minor attains the age of majority or upon further order of this Court. , a minor, whose Social Financial Institution By: Authorized Officer Typed or Printed Name Phone Number Date American LegalNet, Inc. www.FormsWorkFlow.com H.C. FORM 22.3 - VERIFICATION OF RECEIPT AND DEPOSIT 04/01/97