PROBATE COURT OF TRUMBULL COUNTY, OHIO THOMAS A. SWIFT, JUDGE IN THE MATTER OF ______________________________________________________________ CASE NO. _____________________ VERIFICATION OF RECEIPT AND DEPOSIT (Estates of Minors of Not More Than $10,000) Pursuant to Court order, the sum of $_______________________________ was deposited with ______________________________ on the _________________ day of ________________, 20___, as evidenced by Savings/Certificate of Deposit Account Number ______________________. This account is held solely in the name of ______________________________________________, a minor, whose Social Security Number is _____________________________________________. By accepting the deposit for the minor, this institution agrees that the deposit, together with accumulated interest, shall be held and no part thereof released until the minor attains the age of majority or upon further order of this Court. This institution further agrees to divulge to the Court, upon request, the balance in the account and/or the date that the account was closed. _________________________________________ Financial Institution By ______________________________________ Authorized Officer _________________________________________ Typed or Printed Name _________________________________________ Phone Number _________________________________________ Date FORM 22.3A VERIFICATION OF RECEIPT AND DEPOSIT ESTATES OF MINORS OF NOT MORE THAN $10,000 4/97 American LegalNet, Inc. www.FormsWorkflow.com