File No.
STATE OF NORTH CAROLINA
                                                                        In The General Court Of Justice 
                                                                                Superior Court Division
                                         County                                 Before the Clerk

    IN THE MATTER OF THE ESTATE OF:
Name Of Decedent/Trust
                                                                        RECEIPT
Name Of Personal Representative/Trustee
                                                                       PARTIAL  FINAL

                                                         ACKNOWLEDGMENT
I, the undersigned beneficiary, agree that I did receive from the Personal Representative/Trustee of the estate/trust a 
distribution consisting of the following:

                                       DESCRIPTION                              VALUE
                                                                       $

Date                  Name Of Beneficiary (Type Or Print)Signature 

                      Name Of Witness (Type Or Print)    Signature 

AOC-E-521, New 2/01
2001 Administrative Office of the Courts