The undersigned hereby acknowledges receipt from the Personal Representative in this matter of the following
• I am the appointed Conservator for _____________________________ (name of protected person),
under File No. ____________________________ - copy of certificate of appointment is attached.
• All assets to which the Conservatorship is entitled have been received and deposited into the
Conservatorship account – copy of deposit slip is attached.
• I am the appointed Conservator for _______________________________ (name of protected person),
under File No. ______________________ - copy of certificate of appointment is attached.
• All assets to which the Conservatorship is entitled will be handled by Broker: ____________________
________________________ - copy of restricted account agreement is attached.
• All assets to which the Conservatorship is entitled are deposited with said agency – copy of deposit slip
(or agency confirmation) is attached.
In consideration of the above listed distribution, the undersigned hereby releases and forever discharges the
Personal Representative and the Estate from any and all rights and claims, which the undersigned may have
against the Personal Representative and the Estate, and waives right to demand a hearing on all Accountings (if
applicable), Proposals for Distribution (if applicable), and the Application for Settlement.
Executed this _____ day of __________________________, 20_____.
*The Personal Representative is not allowed to serve as the witness. The witness must be a disinterested party--not related to
decedent, beneficiary or personal representative.
RECEIPT AND RELEASE WITH WAIVER
FOR ASSETS RECEIVED FROM AN ESTATE
CASE NUMBER: _______________________
GrCo. FORM L (11/2014)