RECORDED: VERIFICATION RE RESTRICTED ACCOUNT PC-412 NEW 7/13 TO: COURT OF PROBATE, ESTATE OF STATE OF CONNECTICUT COURT OF PROBATE [Type or print in ink.] DISTRICT NO. FIDUCIARY [Name and address] CO-FIDUCIARY [Name and address] FINANCIAL INSTITUTION HOLDING RESTRICTED ACCOUNT(S) [Name and address] ACCOUNT NUMBERS OF RESTRICTED ACCOUNT(S) The account(s) listed above are restricted by an order of the court and an Order and Agreement/Restriction on Control of Assets (PC-411) signed by an authorized agent of the above financial institution and dated _______________________________________ . The order of the court and the signed agreement to restrict assets require that no withdrawal of principal or income shall be permitted from the above restricted accounts, except as noted below, until further order of the court. No withdrawals are authorized. [Any change in the investment held in the account(s) or rollover of the funds to a new account will not be considered a withdrawal, provided that the same restriction shall apply to the new account.] The fiduciary may withdraw interest and/or dividends earned on said account(s) without further court order. The undersigned represents that the court-ordered restriction on the account(s) as listed above remains in force. Dated at: , Connecticut, on [Month, Day, Year] Financial Institution: By: Authorized Agent Print or type name: As used in this document, the word fiduciary includes the plural, where the context so requires. NOTE TO FIDUCIARY The verification of restricted account(s) shall be filed in court, together with a copy of the most recent statement for the above-referenced account(s). VERIFICATION RE RESTRICTED ACCOUNT American LegalNet, Inc. www.FormsWorkFlow.com PC-412
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