JDF 867 SC R 6 / 1 9 ACKNOWLEDGMENT OF DEPOSIT OF FUNDS TO RESTRICTED ACCOUNT Page 1 of 2 District Court Denver Probate Court County, Colorado Court Address: I n the Int erest of : Protected Person /Minor COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom ACKNOWLEDGMENT OF DEPOSIT OF FUNDS TO RESTRICTED ACCOUNT ( name of financial institution ) , acknowledge s that funds have been deposited by (fiduciary) as the Conservator , Guardian, Next Friend , or Parent for ( Protected Person or M inor ) as follows: Title of Account Account Number - last 4 - digits only Amount $ Total $ By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. This institution submits itself to the jurisdiction of t his c ourt and agrees that it will not permit any withdrawal of funds except upon being furnished a certified copy of an o rder of this c ourt authorizing such withdrawal. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the day of , , (date) (month) (year) at (city or other location, and state OR country) American LegalNet, Inc. www.FormsWorkFlow.com JDF 867 SC R 6 / 1 9 ACKNOWLEDGMENT OF DEPOSIT OF FUNDS TO RESTRICTED ACCOUNT Page 2 of 2 (printed name of Authorized Bank Officer ) (signature of Authorized Bank Officer ) Note: Return to the Court name and address as shown above. American LegalNet, Inc. www.FormsWorkFlow.com