JIS CODE: PAR/VFD Approved, SCAO STATE OF MICHIGAN PROBATE COURT COUNTY CIRCUIT COURT - FAMILY DIVISION PROOF OF RESTRICTED ACCOUNT AND ANNUAL VERIFICATION OF FUNDS ON DEPOSIT (CONSERVATORSHIP OF MINOR) FILE NO. In the matter of , minor USE NOTE: This form must be completed and filed with the court within 28 days of the conservator's qualification, or as otherwise ordered by the court, and annually thereafter. Name of financial institution/insurance company/brokerage firm Address Telephone no. Name of authorized representative Title I certity that the estate funds of the minor are currently on deposit with us under a restricted account as follows: Type of account Account number Balance Account caption (include name of conservator) Attached is a copy of the corresponding financial institution's statement. I further certify that 1. The funds, including accruals, shall not be released or withdrawn except by written order of this court. 2. Records have been marked to prohibit withdrawal except by written order of this court. 3. We are liable for funds released or withdrawn without written order of this court. Date Signature of authorized representative Do not write below this line - For court use only PC 669 (9/08) PROOF OF RESTRICTED ACCOUNT AND ANNUAL VERIFICATION OF FUNDS ON DEPOSIT (CONSERVATORSHIP OF MINOR) MCR 5.409(C)(4) American LegalNet, Inc. www.FormsWorkflow.com