Proof Of Restricted Account And Annual Verification Of Funds On Deposit (Conservatorship Of Minor) {PC 669}

Approved, SCAO JIS CODE: PAR STATE OF MICHIGAN PROBATE COURT COUNTY CIRCUIT COURT - FAMILY DIVISION PROOF OF RESTRICTED ACCOUNT AND ANNUAL VERIFICATION OF FUNDS ON DEPOSIT (CONSERVATORSHIP OF MINOR) FILE NO. In the matter of , minor USE NOTE: This form must be completed and filed with the court within 14 days of the conservator's qualification, or as otherwise ordered by the court, and annually thereafter. Name of financial institution/insurance company/brokerage firm Address Name of authorized representative Title Telephone no. I certity that the estate funds of the minor are currently on deposit with us under a restricted account as follows: Type of account Account caption (include name of conservator) Account number Balance Attached is a copy of the statement reflecting this information. I further certify that: 1. The funds, including accruals, shall not be released or withdrawn except by written order of this court. 2. Records have been marked to prohibit withdrawal except by written order of this court. 3. We are liable for funds released or withdrawn without written order of this court. 4. The funds are, and will continue to be, invested in those investments permitted by Michigan law governing investments by fiduciaries. Date Signature of authorized representative Do not write below this line - For court use only PC 669 (11/05) PROOF OF RESTRICTED ACCOUNT AND ANNUAL VERIFICATION OF FUNDS ON DEPOSIT MCR 5.409(C)(4) (CONSERVATORSHIP OF MINOR) American LegalNet, Inc. www.FormsWorkflow.com