CONNECTICUT PROBATE COURTS Verification R e: Restricted Account PC - 412 R EV. 1/1 9 Verification RRestricted Account PC - 412 RECEIVED: Instructions: 1) A fiduciary may provide this form to a financial institution to obtain a verification that a court - ordered restriction on accounts held or managed by the financial institution remains in force. 2)The fiduciary must submit an original verification signed by an authorized agent of the financialinstitution to the Probate Court whenever the fiduciary is required to submit a financial report or account. 3)The fiduciary must attach a copy of the most recent statement for each restricted account listed on thisverification. 4)For more information, see Probate Court Rules of Procedure, section 35.7(e).5)Type or print the form in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court 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) Account Numbers of Restricted Accounts The accounts listed above are restricted by an order of the court and an Order and Agreement/Restriction on Control of Assets (PC-411) signed by an authorized agent of the above financial institution and dated . The order of the court and the signed agreement to restrict assets require that no withdrawal of principal or income shall be permitted from the above restricted accounts, except as noted below, until further order of the court. No withdrawals are authorized. [Any change in an investment held in the account or rollover of the funds to a new account will not be considered a withdrawal, provided that the same restriction shall apply to the new account.] The fiduciary may withdraw interest and/or dividends earned on the account without further court order. The undersigned represents that the court-ordered restriction on the account as listed above remains in force. Financial Institution Signature of Authorized Agent Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com