STATE OF MICHIGAN COUNTY OF GENESEE PROBATE COURT STATEMENT BY ATTORNEY TO RESTRICT MONIES CASE NO. IN THE MATTER OF: I, _______________________________________________________, attorney, hereby assume responsibility to see that all funds due and owing said minor will be deposited into an account at a lending institution, stock company, or bank of the Conservator's choice. Further, said monies are to be placed into a restricted account with no withdrawals without an Order of this Court. I will provide the Court with the Proof of Restricted Account form )PC 669). __________________ Date ___________________________________________________ Signature of Attorney Bar# ___________________________________________________ Address ___________________________________________________ City, State, Zip ___________________________________________________ Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com