IN THE CIRCUIT COURT OF CLAY COUNTY, MISSOURI SEVENTH JUDICIAL CIRCUIT DIVISION FOUR Liberty, Missouri 64068 Case No. ______________________ Matter of _____________________________________________, a minor. VERIFICATION OF FUNDS IN RESTRICTED DEPOSIT UNTIL MINOR REACHES AGE 18 The undersigned hereby certifies that he is an official of the below-named depository, which has on deposit $___________________________ in the separate name of _____________________________________, minor. Said deposit has been accepted under the terms of the Court order entered on the ________ day of ________________, 20______, by Division Four of the Circuit Court of Clay County, Missouri, the entire amount, plus interest, will be paid to the minor on said minor’s 18th birthday, which will be _________________________, and not before, without further order of the court. THE STATEMENTS AND REPRESENTATIONS IN THIS DOCUMENT ARE MADE UNDER OATH AND ARE TRUE AND CORRECT TO MY BEST KNOWLEDGE AND BELIEF. I UNDERSTAND THEY ARE MADE SUBJECT TO THE PENALTIES OF MAKING A FALSE AFFIDAVIT OR DECLARATION. Date ________________________ Depository ________________________________________________ Address __________________________________________________ _________________________________________________________ By (signature) ______________________________________________ Title _____________________________________________________ Form DIV4-401 Revised 5/31/2011 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com