STATE OF SOUTH CAROLINA	)
)	IN THE PROBATE COURT
COUNTY OF:	)
)	RECEIPT
IN THE MATTER OF:	)
)	CASE NUMBER:

The undersigned hereby acknowledge receipt from the conservator in this matter of the following property:

Executed this day of , 20 .

Witness:
Recipient:

FORM #563PC (2/2004)

SCPC administrative

STATE OF SOUTH CAROLINA

SGibbs

2004-02-10

HMcCaw

SC Judicial Dept.