State of Minnesota County of _____________________ District Court ________________ Judicial District Probate / Mental Health Division Court File No. ________________________ Case Type: 14, Conservatorship In Re: Conservatorship of ____________________________, Protected Person Verification of Funds on Deposit By Financial Institution (File as a Financial Source Document with Form 11.2) To: Name and Address of Financial Institution: _______________________________________________ _______________________________________________ _______________________________________________ I am the court appointed conservator in this matter and your financial institution has funds on deposit for the above named protected person. Please provide me with verification of the accounts listed below as of by completing and signing the bottom the following date: portion of this form and affixing your official bank seal. Dated: Signature of Conservator Conservator's name and address: Verification of Funds on Deposit by Financial Institution I certify that the foregoing amounts were on deposit as shown by the records of this financial institution listed below. The accounts listed below were accurate as of this date: Account Information: Depositor Account Title Interest Earned Type of Account Account Number Current Rate of Interest Current Balance (including interest) By: SIGNATURE OF CERTIFYING FINANCIAL INSTITUTION OFFICIAL DATE Title of Certifying Official (Please affix official bank seal on this form) 15-UVF State ENG Rev 9/09 www.mncourts.gov/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com