Santa Clara — Sample

Source: https://santaclara.courts.ca.gov/system/files/sample_receipt_from_distributee_0.pdf

1 Name, Address and Telephone Number of Person Without Attorney:

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3

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5 In Pro Per

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7

8 SUPERIOR COURT OF THE STATE OF CALIFORNIA

9 COUNTY OF SANTA CLARA

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11 In the Matter of the Estate of ) Case No.: ) 12 ) RECEIPT FROM DISTRIBUTEE FOR ) PROPERTY RECEIVED (Prob.C. §11751) 13 ) ) 14 Decedent. ) ) 15 )

16 I, (name), say:

17 I acknowledge receipt from (name), the personal

18 representative of the estate of (name), deceased, of all

19 of the property distributed to me in accordance with the decree of distribution in the above-

20 entitled proceeding on _________________ (name).

21 The property so distributed to and received by me is described as follows:

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23 (describe, e.g., money in the sum of $_________________).

24 I declare under penalty of perjury under the laws of the State of California that the

25 foregoing is true and correct. Executed on (date) at (city),

26 (state).

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28 (Type or print name of distributee) (Signature)

Receipt from Distributee for Property Received