Proof Of Restricted Account From Depository Or Financial Institution {PBC91f}

Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Licensed Fiduciary Number: ____________________________________ Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent FOR CLERK'S USE ONLY SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY In the Matter of the Conservatorship of: Case Number PB: (Name of Protected Person) Name of Depository: Address of Depository: 1. PROOF OF RESTRICTED ACCOUNT FROM DEPOSITORY OR FINANCIAL INSTITUTION This Depository has opened the following account(s) for the above-named protected person In the name of "The estate of ", a protected person, , Conservator", as follows: by TYPE LAST 4 DIGITS of ACCOUNT NUMBER ONLY (Show other numbers as "X" as in "XXXX1234) $ $ $ BALANCE 2. Unless otherwise ordered by the court, each account listed is a federally insured account, restricted as follows: No withdrawals of principal, income, or interest will be allowed without certified order of the Superior Court. Reinvestments may be made without further court order so long as funds remain insured and restricted in this institution at this branch. If the protected person is a minor, funds shall not be released to the minor at age eighteen (18) without certified court order authorizing release of the funds. I have received a certified copy of the Court's order dated agree, on the Depository's behalf, to comply with the order. Dated , and I 3. Representative's Signature and Title* STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: Representative's PRINTED Name and Title by (date) . (notary seal) © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Deputy Clerk or Notary Public Page 1 of 1 PBC91f - 050115 American LegalNet, Inc. www.FormsWorkFlow.com