Affidavit And Acknowledgment Of Restriction

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF MARION PROBATE DEPARTMENT In the Matter of the * Conservatorship ) * UTMA Account of ) CASE NO. ) , ) AFFIDAVIT AND ACKNOWLEDGMENT Protected Person. ) OF RESTRICTION STATE OF OREGON ) ) ss. County of ) I, , being duly sworn, depose and say: 1. I am employed by in the capacity of * . In this capacity, I am aware of the existence and status of the followin g* conservatorship * Uniform Transfers to Minors Act (UTMA) account: Account number: Dividends / interest income are:Account balance: $ * Reinvested / remain in the accountShare value: $ * Other: Number of shares: 2. This institution has received a copy of the court order si gned on , 200 that restricts the above account and provides that no disbursements may be made from the account without court order. By accepting this account, this institution agrees to abide by and bebound by that order, and to be subject to the jurisdiction of the court that entered that order. Therestriction shall continue until the court orders that the restriction terminate or the protected personreaches a ge 18, whichever occurs first. 3. I certify that the account described above is listed with this institution as a restrictedaccount, from which funds shall be disbursed only upon court order. I further certify that thisrestriction is noted system wide in the computer network of this institution. DATE: , 200 . __________________________ *NOTE: THIS AFFIDAVIT (Name of financial institution) MUST BE SIGNED BY THE BRANCH MANAGER By: OR THE EQUIVALENT Title: SUBSCRIBED AND SWORN to before me this day of , 200 . Notary Public for Oregon AFFIDAVIT AND ACKNOWLEDGMENT OF RESTRICTION affrestr.wpd Rev. 1/24/01