Your Name: Your Address: Your City, State, Zip Code: Your Telephone Number: State Bar Number: (if applicable): Represents Self, without a lawyer OR Attorney for 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) PROOF OF RESTRICTED ACCOUNT FROM DEPOSITORY OR FINANCIAL INSTITUTION Name of Depository: Address of Depository: 1. This Depository has opened the following account(s) for the above-named protected person in the name of “The estate of ______________________________________________”, a protected person, by , Conservator” as follows: TYPE LAST 4 DIGITS of ACCOUNT NUMBER ONLY (Show other numbers as “X” as in “XXXX1234) BALANCE $ $ $ 2. Each account listed is a restricted account. No withdrawals of principal or interest will be allowed unless the Superior Court permits withdrawals by certified court order. Reinvestments may be made without an order of the Court if each account remains restricted and at this Depository. However, money deposited into a mutual fund approved by the Court may not be transferred to any other fund without prior Court approval other than to a money market fund. If the protected person is a minor, funds shall not be released when the minor turns eighteen until receipt of a court order authorizing release of the funds. 3. I have received a certified copy of the Court's order restricting these accounts dated and I agree, on the Depository’s behalf, to comply with the order. Dated Manager’s Signature and Title* Manager’s PRINTED Name and Title *Must be signed by a Bank Branch Manager or a Resident Manager for an Investment Securities Dealer. Sworn to or Affirmed before me this date: My Commission Expires: (or Seal below) Notary Public © Superior Court of Arizona in Maricopa County April 22, 2009 ALL RIGHTS RESERVED PBC91f Page 1 of 1 Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com