Approved, SCAO JIS CODE: PUF STATE OF MICHIGAN PROBATE COURT COUNTY OF In the matter of FILE NO. PETITION AND ORDER TO USE FUNDS (CONSERVATORSHIP) PETITION 1. I, Name , am conservator of the estate. 2. The interested persons, addresses, and their representatives are identical to those appearing on the initial application/petition, except as follows: (For each person whose address changed, list the name and new address; attach separate sheet if necessary.) 3. As of Date the ward's total assets are $ . 4. I REQUEST permission to withdraw $ of the ward's money from to be used as follows for the benefit of the ward: Account no. and name of financial institution I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Attorney signature Name (type or print) Address City, state, zip Telephone no. Bar no. Petitioner signature Petitioner name (type or print) Address City, state, zip Telephone no. ORDER IT IS ORDERED: 5. The petition is denied. 6. The petition is granted. The conservator is authorized to withdraw $ from the account stated in the petition. If access to these funds was restricted, access to the remainder of the funds is still restricted. Receipts or proof that the money was spent for the requested purpose shall be filed with this court by . 7. Other: Date Judge Date Bar no. I certify that I have compared this copy with the original on file in this court and that it is a correct copy of the original. Date Deputy register Instructions to Financial Institution: Do not accept any document other than a certified copy of this order with the court seal. Please retain this certified copy. USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form. Do not write below this line - For court use only PC 673 (9/12) PETITION AND ORDER TO USE FUNDS (CONSERVATORSHIP) MCL 700.5427 American LegalNet, Inc. www.FormsWorkFlow.com