Nebraska State Court Form REQUIRED PROOF OF RESTRICTED ACCOUNT FROM DEPOSITORY OR FINANCIAL INSTITUTION CC 16:2.11 Revised 09/13 Neb. Ct. R. §6-1442(D) NOTICE: To protect personal information, only the last four digits of the account should be provided on this form. Complete account information is provided on the Personal and Financial Information for Guardianships and Conservatorships form (CC 16:2.23). IN THE COUNTY COURT OF ________________COUNTY, NEBRASKA IN THE MATTER OF ___________________________ Ward/Incapacitated Person/Protected Person Case #____________________ PROOF OF RESTRICTED ACCOUNT FROM DEPOSITORY OR FINANCIAL INSTITUTION Name of Bank/Financial Institution: Address of Bank/Financial Institution: 1. This Financial Institution has opened the following account(s) for the above-named ward/incapacitated person/protected person in the name of ,a ward/incapacitated person/protected person, by , guardian/conservator, as follows: TYPE OF ACCOUNT ACCOUNT NUMBER (last four digits only) (Show all other numbers as "X" as in "XXXX1234) BALANCE 2. Each account listed is a restricted account. No withdrawals of principal or interest will be allowed unless the court permits withdrawals by certified court order. Reinvestments may be made without an order of the court if each account remains restricted and at this Depository. Page 1 of 2 Proof of Restricted Account from Depository or Financial Institution CC 16:2.11 Rev 09/13 American LegalNet, Inc. www.FormsWorkFlow.com I have received a certified copy of the court's order restricting these accounts dated _________________ and I acknowledge, on the Depository's behalf, that the account is designated as a restricted account and the depository will continue to comply with the order. Manager's Signature and Title** Date (**Must be signed by a Bank Manager or a Manager for an Investment Securities Dealer or their designee.) State of County of ) ) ss. ) , this Name of Manager signing above day of Day (title or rank) Month , Year . Notary Public (signature of person taking acknowledgment) My commission expires: (serial number, if any) The foregoing instrument was acknowledged before me by Page 2 of 2 Proof of Restricted Account from Depository or Financial Institution CC 16:2.11 Rev 09/13 American LegalNet, Inc. www.FormsWorkFlow.com