SEALED (Copy Receipt) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: (Clerk’s Date Stamp) CASE NO. ________________________ RECEIPT OF FUNDS INTO BLOCKED ACCOUNT (RCP) ________________________________________ SEALED FINANCIAL SOURCE DOCUMENT Clerk’s Action Required COMPLETE A SEALED CONFIDENTIAL GUARDIANSHIP DOCUMENT COVER SHEET RECEIPT is hereby acknowledged of $_________________ dollars deposited with the undersigned by __________________________, who is the Personal Representative, Guardian, Guardian ad Litem or attorney for the person named in the caption above. The deposit was made into Account No.______________________. The undersigned financial institution agrees to hold this account, and any subsequent deposits to the account, and not allow withdrawal therefrom except under Order of the Court. I certify (or declare) under penalty of perjury under the laws of the State of Washington that to the best of my knowledge the statements above are true and correct. #37-RECEIPT OF FUNDS INTO BLOCKED ACCOUNT PAGE 1 OF 2 Revised 5/07 American LegalNet, Inc. www.FormsWorkflow.com SIGNED AT_________________, WASHINGTON THIS _____ DAY OF_________________, 20___. Authorized Signature Printed Name of Person Signing/Title Name of Bank or Financial Institution Branch Name Address City, State, Zip Code Telephone/Fax Number Email Address #37-RECEIPT OF FUNDS INTO BLOCKED ACCOUNT PAGE 2 OF 2 Revised 5/07 American LegalNet, Inc. www.FormsWorkflow.com