RECEIPT OF BENEFICIARY OF ESTATE

1 RECEIPT OF BENEFICIARY OF ESTATE Re: ESTATE of _____, deceased The undersigned BENEFICIARY of the above referenced ESTATE hereby acknowledges RECEIPT of the following distributions from the ESTATE by the personal representative: _____ _____ _____ Witness the following signature this ____day of _____, 20___.

2 _____ BENEFICIARY _____ Please print your legal name State of _____ City/County of _____ Personally appeared before me the undersigned notary public, the above referenced BENEFICIARY , who acknowledged his/her signature this ___day of _____.

3 20__. _____ Notary Public My commission expires: _____ Registration Number: _____ SEAL.