Nebraska State Court Form CC 16:2.6 New 11/2011 ACKNOWLEDGMENT OF FINANCIAL INSTITUTION REQUIRED Neb. Ct. R. §6-1443(A)(2); §61443(B) IN THE COUNTY COURT OF ______________ COUNTY, NEBRASKA CASE NUMBER:_______________________ IN THE MATTER OF ACKNOWLEDGMENT OF FINANCIAL INSTITUTION Ward/Protected Person/Incapacitated Person I, _____________________________________ of ________________________________________, (Name) (Financial Institution) Date solemnly swear that on ___________________________, we received copies of: Order Appointing Conservator and/or Guardian. Letters of Conservatorship and/or Guardianship (Please check which of the above you have received) in the above referenced case and any restrictions thereon. This Financial Institution acknowledges that attached to this document is a printout of all assets of the above ward held at this financial institution, as listed below: TYPE OF ACCOUNT * ACCOUNT NUMBER (LAST 4 DIGITS ONLY*) (SHOW OTHER NUMBERS AS "X" AS IN "XXXX1234" BALANCE _____________________________________________________ (Signature and Title of Certifying Official) *To protect personal information, only the last 4 digits of the account should be provided on this form. Complete account information is provided on the Personal and Financial Information of Parties form (CC 16:2.23). Page 1 of 2 Acknowledgment of Financial Institution CC 16:2.6 New 11/2011 American LegalNet, Inc. www.FormsWorkFlow.com State of County of ) ) ss. ) The foregoing instrument was acknowledged before me by Name , this . day of Day Month Year , __________________________________________________ Notary Public (Signature of Person Taking Acknowledgment) __________________________________________________ (Title or Rank) (Serial Number, if any) My commission expires: _______________________________ Page 2 of 2 Acknowledgment of Financial Institution CC 16:2.6 New 11/2011 American LegalNet, Inc. www.FormsWorkFlow.com