Verification Of Restricted Deposit
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Verification Of Restricted Deposit Form. This is a Missouri form and can be use in 7th Circuit (Clay County) Local Circuit Courts.
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Tags: Verification Of Restricted Deposit, 406, Missouri Local Circuit Courts, 7th Circuit (Clay County)
CIRCUIT COURT OF CLAY COUNTY, MISSOURI
PROBATE DIVISION
No.
Matter of
, *minor - *disabled - *deceased
VERIFICATION OF RESTRICTED DEPOSIT
The undersigned hereby certifies that __he is an official of the below named depository, which had (a)
deposit(s) on the ______ day of _____________________, 20___. The following amount(s) in the name of
, as *Conservator__, *Personal Representative__, of the estate of
__
___ *minor__, *disabled__, *deceased. THERE ARE NO
OTHER NAME(S) ON THE ACCOUNT(S) EXCEPT AS FOLLOWS:
__
Said deposit(s) have been made and accepted with the specific contract and agreement that they are
subject to the order of the Probate Division of the Circuit Court of Clay County, Missouri and no withdrawals
will be permitted from such restricted accounts except on the order of the Court, however, the Conservator
may change the type of account within this depository without Court order.
Account
Type:
Savings,
CD, MM,
etc.
Account Number
Interest
Rate
Due Date on
CD
Total Amt in
Acct.
Date of
Last Int.
Pymt.
Is Interest
restricted?
YES__ or NO__
THE STATEMENTS AND REPRESENTATIONS IN THIS DOCUMENT ARE MADE UNDER OATH
AND ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND
THEY ARE MADE SUBJECT TO THE PENALTIES OF MAKING A FALSE AFFIDAVIT OR DECLARATION.
Date:____________________
Depository:
Address:
By:
TYPE OR PRINT NAME
SIGNATURE ( REQUIRED )
Title:
INSTRUCTIONS: Do not restrict regular checking accounts. Any erasures or corrections must be initialed by a
depository agent.
*strike if inapplicable
Form 406
Revised 9/23/2004
Page 1 of 1
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