Nebraska State Court Form REQUIRED APPLICATION FOR WITHDRAWAL OF FUNDS CC 16:2.19 Page 1 of 1 Application for Withdrawal of Funds CC 16:2.19 Rev IN THE COUNTY COURT OF COUNTY, NEBRASKA IN THE MATTER OF THE GUARDIANSHIP/CONSERVATORSHIP OF Ward/Incapacitated Person/Protected Person Case APPLICATION FOR WITHDRAWAL OF FUNDS I, , the guardian/conservator, request from the court approval to withdraw $ from the assets of the ward/incapacitated person/protected person for the following reason(s): The full amount will be spent on behalf of the ward/incapacitated person/protected person. This expenditure is necessary and for the best interests of the ward/incapacitated person/protected person, considering all the circumstances of the ward/incapacitated person/protected person and those liable for his/her support. I, the undersigned guardian/conservator, swear or affirm, under the penalties of perjury, that I have examined the above documents, and to the best of my knowledge and belief, they are true, correct and complete. Date Signature(s) of Guardian(s) and/or Conservator(s) Print or Type Name of Guardian(s) and/or Conservator(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box of Guardian(s) and/or Conservator(s) City/State/ZIP Code of Guardian(s) and/or Conservator(s) Phone(s) E-mail Address(es) American LegalNet, Inc. www.FormsWorkFlow.com