In the Matter ofName of Minor or Disabled Person, Guardian of the Property forPROOF OF RESTRICTED GUARDIANSHIP ACCOUNTThis is to certify that on of , , funds in the amount of$ were deposited into account number .That account is registered as follows:NOTE: Use this form if you are a guardian of the property and the court ordered you to place guardianshipfunds in a restricted account. File the original form with the court no later than 60 days from the date ofappointment or as the court otherwise directs. If the minor or disabled person has more than $200,000 inassets, you may need to set up multiple restricted accounts. File a form for each account.CC-GN-024 (12/2017)Docket reference CIRCUIT ORPHANS' COURT FOR , MARYLANDCase No.City/CountyCourt AddressLocated atFinancial Institution(Md. Rule 10-705)AddressCity, State, ZipAuthorized Official's Signature DatePrinted NameTelephoneName of GuardianName of Minor or Disabled PersonSUBJECT TO WITHDRAWALS ONLY UPON ORDER OF THECircuit CourtOrphans' Court for .City/CountyDayMonthYear American LegalNet, Inc. www.FormsWorkFlow.com