CONNECTICUT PROBATE COURTS Request Re: Withdrawal of Funds From Restricted Account PC - 413A R EV . 1/1 9 Request Re:Withdrawal of Funds from Restricted Account PC - 413A RECEIVED: Instructions: 1) A fiduciary may use this form to request authorization to withdraw funds from a court - ordered restricted account. 2)Describe the purpose of the withdrawal, and attach a copy of the most recent statement for therestricted account and documentation substantiating the amount of the request. 3)For more information, see Probate Court Rules of Procedure, section 35.7(f).4)Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Cour t Name District Number Estate of Fiduciary (Name, address and telephone number) Co-Fiduciary (Name, address and telephone number) Financial Institution (Name, address and telephone number) Restricted Account Number The fiduciary requests an order from the court to authorize the fiduciary to withdraw the sum of $ from the above restricted account. The purpose of the withdrawal is: Signature of Fiduciary Type or Print Name Date Signature of Fiduciary Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com