State of Minnesota County of ______________________ In Re: Conservatorship of ____________________________, Protected Person District Court ________________ Judicial District Probate / Mental Health Division Court File No. __________________________ Case Type: 14, Conservatorship Verification of Stocks and Other Securities By Broker / Financial Advisor / Financial Institution (File as a Financial Source Document with Form 11.2) To: Name and Address of Broker / Financial Advisor / Financial Institution: _______________________________________________ _______________________________________________ _______________________________________________ I am the court appointed conservator in this matter and you and/or your financial institution has stocks and other securities for the above named protected person. Please provide me with verification of the by completing and assets listed below as of the following date: signing the bottom portion of this form and affixing your official seal. Dated: Signature of Conservator Conservator's name and address: Verification of Funds on Deposit by Financial Institution I certify that the foregoing stocks and other securities were on deposit as shown by the records of this financial institution listed below. The stocks and other securities listed below were accurate as of this date: Account Information: Number of Name of Stock or Account Title Units/Shares Note: Attach a separate sheet if more space is needed to list account information / remarks. By: SIGNATURE OF CERTIFYING BROKER / FINANCIAL ADVISOR / FINANCIAL INSTITUTION OFFICIAL DATE TITLE OF CERTIFYING OFFICIAL (Please affix official seal on this form) American LegalNet, Inc. www.FormsWorkFlow.com 15-UVS State ENG Rev 9/09 www.mncourts.gov/forms Page 1 of 1