JDF 868 SC R 6 /1 9 MOTION TO WITHDRAW FUNDS FROM RESTRICTED ACCOUNT Page 1 of 2 District Court Denver Probate Court County, Colorado Court Address: I n the Interest 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 MOTION TO WITHDRAW FUNDS FROM RESTRICTED ACCOUNT I, ( c onservator (s) ) , respectfully request authority to withdraw $ , on deposit in the restricted account (s) listed below: Attach current bank statement. Name and Address of Financial Institution Account Number (last 4 - digits only) Current Balance in Account $ Total $ The funds are requested for the following purchase/ reasons(s): Attach supporting documentation for your request . 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. Date: Signature of Minor if 12 years of age or over VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the day of Executed on the day of (date) (date) , , , , (month) (year) (month) (year) at at (city or other location, and state OR country) (city or other location, and state OR country) (printed name) (printed name) (Signature of Conservator/Successor) (Signature of Co - C onservator/Successor , if any) American LegalNet, Inc. www.FormsWorkFlow.com JDF 868 SC R 6 /1 9 MOTION TO WITHDRAW FUNDS FROM RESTRICTED ACCOUNT Page 2 of 2 Attorney Signature, (if any) Date CERTIFICATE OF SERVICE I certify that on (date), a copy of this (name of document) was served as follows on each of the following: Name and Address Relationship to Decedent, Ward, or Protected Person Manner of Service* *Insert one of the following: hand delivery, first - class mail, certified mail, e - service, or fax. Signature American LegalNet, Inc. www.FormsWorkFlow.com