Nebraska State Court Form REQUIRED CERTIFICATE OF PROOF OF POSSESSION CC 16:2.13 2476-1442 Page 1 of 2 Certificate of Proof of Possession CC 16:2.13 Rev TO THE GUARDIAN AND/OR CONSERVATOR: This form must be completed by In the matter of the estate of CERTIFICATE OF BALANCE ON DEPOSIT I CERTIFY that on the day of , 20 , there was on deposit in this nstitution to thebenefit of the above ward, incapacitated or protected Checking Account, No. XXXXXXX- Restricted Balance of $ including interest of $ paid during period of statement of account. Savings Account, No. XXXXXXX- Restricted Balance of $including interest of $ paid during period of statement of account. Please Note: To be consider (*Extend above format for additional accounts as required) NOTE TO CERTIFYING OFFICIAL: This certificate may be executed by a bank official, an authorized official or agent of the company which is surety on your bonds. Date Address of Certifying Official Signature and Title of Certifying Official State of ) enCounty of ) The foregoing instrument was acknowledged before me by , this Name of Official certifying above day of , . Day Month Year Notary Public (signature of person taking acknowledgment) My commission expires: (title or rank) (serial number, if any) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Certificate of Proof of Possession CC 16:2.13 Rev CERTIFICATE AS TO SECURITIES (certificates of deposits, savings bonds, etc.) KIND OF BOND OR SECURITY DATE OF PURCHASE COST INTEREST RATE PRESENT VALUE Restricted 1. Restricted 2. Restricted 3. Restricted 4. Restricted (identify U.S. Savings Bonds by series, last four digits of bond, purchase date, and cost. Identify accounts by last four digits of account.) (*extend format for additional bonds or securities as required) I CERTIFY that the securities listed above were exhibited to me by the above-named guardian and/or conservator as being the property of the estate of the ward, protected or incapacitated person said securities then and there being in the custody and control of the guardian and/or conservator. Date Address of Certifying Official Signature and Title of Certifying Official State of ) en) ss. County of ) The foregoing instrument was acknowledged before me by , this Name of Official certifying above day of , . Day Month Year Notary Public (signature of person taking acknowledgment) My commission expires: (title or rank) (serial number, if any) American LegalNet, Inc. www.FormsWorkFlow.com