IN THE CIRCUIT COURT OF THE STATE OF OREGON THIRD JUDICIAL DISTRICT Probate Department In the Matter of the: “ Conservatorship “ Protective Proceeding for: ) ) ) ) ____________________________________, ) A Minor Protected Person (the “child”). ) Case No. MOTION AND ORDER FOR RELEASE OF RESTRICTED FUNDS _______________________________________ (“Parent”) moves the Court for an order approving the release of restricted funds, and respectfully represents: 1. Under the terms of the order approving the personal injury settlement, the parents of Child must obtain court approval before withdrawing any money from any account holding the personal injury proceeds. 2. Parent requests authority to withdraw from __________________________________ (name of financial institution) Account #________________________ the sum of $__________ for the following purposes: _______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Supporting documents (such as statements, estimates, invoices, and so on) are attached. 3. This request for funds is based on the following emergency: _____________________ ______________________________________________________________________________ 4. Although I, as a parent, have a duty to support my child, it is appropriate for the requested expenses to be paid from my child’s funds because: ____________________________ ______________________________________________________________________________ ______________________________________________________________________________ WHEREFORE, Parent prays for an order of this Court granting authority to withdraw the MOTION AND ORDER FOR RELEASE OF RESTRICTED FUNDS - Page 1 of 2 FC (10/20/04) American LegalNet, Inc. www.USCourtForms.com sum of $________________ from _______________________________________ (name of financial institution) Account #__________________ for the purposes described above. Dated: ______________________________ ___________________________________ Signature of Parent ___________________________________ Print Name We consent to this motion and waive notice and time to object: _______________________________________ ___________________________________ Signature of Protected Person (if age 14 or over) Signature of Other Parent _______________________________________ ___________________________________ Print Name Print Name A check for $5.50, payable to the State of Oregon, is included to cover the costs of a certified copy of this motion and order. ORDER “ Allowed. The institution holding funds may release $____________ directly to ______________________________________. No other releases of funds are authorized by this order. “ Denied. Dated:_________________________ __________________________________ Circuit Court Judge __________________________________ Print, Type or Stamp Name of Judge Submitted by: ______________________________________ Name Bar No. (if any) _______________________________________ Address _______________________________________ City, State, Zip _______________________________________ Telephone _______________________________________ E-mail Fax MOTION AND ORDER FOR RELEASE OF RESTRICTED FUNDS - Page 2 of 2 FC (10/20/04) American LegalNet, Inc. www.USCourtForms.com