_____________________________________ (hotel or motel) hereby accepts this envelope and its contents for safekeeping assuming the following conditions are met:

We assume no liability for items valued over _____________ dollars ($________). Therefore any item exceeding this amount cannot be covered for any more than __________________________ dollars ($________).

The employee accepting this envelope has no authority to accept if the contents are valued at more than ______________________ dollars ($_______).

The net worth of the contents of this envelope is no more than _____ dollars ($______).

Signature of depositor: _________________________

Deposit received by: ___________________________

Date: ______________________________________

Signature of depositor: _________________________

Delivered by: _______________________

Dated: _______________________

Package will only be delivered to the party whose signature appears on the duplicate check, which is attached to the package.