Investment Certification {NHJB-2167-P}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) INVESTMENT CERTIFICATION I, (Name) , (Official capacity or position) of (Name of Institution) , (Address of Institution) , County do hereby certify and attest that in accordance with the decree of the Probate Division dated (Guardian name) , the following deposits/investments were made by , as guardian of (Ward name) Form of Deposit/ Investment Account or Certificate Number Date of Deposit/ Investment $ $ $ Amount I further certify and attest that the foregoing deposits/investments have been restricted with notation recited on its/their face, that no withdrawal, encumbrance or other disposition may be made without express written court order; and a copy of the referenced court decree has been made part of the investment records. My telephone number is . Date Signature of official State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title NHJB-2167-P (07/01/2011) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com