I don't have a sample, but basically it's an agreement that the boxholder will not come after the bank legally if there is any dispute as to the contents of the box that are forwarded to her. It also surrenders the boxholder's tenancy and releases the box to the bank for rental to others.
It's not something you want to draw up without counsel's input, IMO.
For what it's worth, we used to involve a notary not in our employ when we did the rare box opening in this way. The notary attested to the accuracy of the inventory. I know there have been a lot of changes in notarial practice, so this may not be done any longer.
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John S. Burnett
BankersOnline.com
Fighting for Compliance since 1976
Bankers' Threads User #8