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Affidavit And Acknowledgment Of Restriction Form. This is a Oregon form and can be use in Marion Local County.
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Tags: Affidavit And Acknowledgment Of Restriction, Oregon Local County, Marion
IN THE CIRCUIT COURT OF THE STATE OF OREGON
THIRD JUDICIAL DISTRICT
Probate Department
In the Matter of the:
)
)
Conservatorship UTMA Account of: )
)
_____________________________________ )
A Protected Person. )
STATE OF OREGON
County of ______________
)
)
)
Case No.
AFFIDAVIT AND
ACKNOWLEDGMENT OF
RESTRICTION
ss.
I , _______________________________________, being duly sworn, depose and say:
1. I am employed by ______________________________________ in the capacity of
_________________________________*. In this capacity, I am aware of the existence and
status of the following conservatorship Uniform Transfers to Minors Act (UMTA)
account:
Account number:
Account balance:
Share value:
Number of shares:
________________________
$_______________________
$_______________________
________________________
Dividends/interest income are:
Reinvested/remain in the account
Other: _____________________
2. This institution has received a copy of the court order signed on _________________,
20________ that restricts the above account and provides that no disbursements may be made
from the account without a court order. By accepting this account, this institution agrees to abide
by and be bound by that order, and to be subject to the jurisdiction of the court that entered that
order. The restriction shall continue until the court orders that the restriction terminate or the
protected person reaches age 18, whichever occurs first.
3. I certify that the account described above is listed with this institution as a restricted
account, from which funds shall be disbursed only upon court order. I further certify that this
restriction is noted system wide in the computer network of this institution.
Date:___________________________
*NOTE: THIS AFFIDAVIT MUST BE SIGNED BY
THE BRANCH MANAGER OR EQUIVALENT
___________________________________
Name of Financial Institution
By:_________________________________
Title: ______________________________
SUBSCRIBED AND SWORN to before me this _____ day of _______________, 20____.
__________________________________
NOTARY PUBLIC FOR OREGON
My Commission expires: _____________
AFFIDAVIT AND ACKNOWLEDGMENT OF RESTRICTION - Page 1 of 1
FC (9/23/04)
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