Kıymetli Evrak ve Değerli Şeylerin Alındı Makbuzu 

Teslim edenin adı, soyadı   ……………………………………………………………………..

Kıymetli evrak ve değerli şeylerin kaydına ilişkin defter numarası: ………………………………

Teslim  alınan  şeyin

                                                                                               Takdir edilen kıymeti

      Cinsi  ve  niteliği                           Miktarı                     Lira                           Kuruş 

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            Yukarda cins ve miktarı yazılı …………………………………………………………………………..

kalem ayniyat alınmıştır.

                                                                                  ……./……/………

Teslim edenin adı,soyadı                                                        İcra Müdürü veya Yrd. 

                                                                                   Adı, soyadı

                                                                                                         Mühür ve İmza