American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR COUNTY Probate Department In the matter of the Guardianship Estate of: A Protected Pers on Deceased ) ) ) ) ) ) Case No DEPOSITORY CERTIFICATION OF FUNDS ON DEPOSIT I hereby certify that the following funds were on deposit in the name of this conservatorship/ estate as of (date): Account # (last 4 digits) Type of Account Balance Maturity I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand that it is made for use as evidence in court and subject to penalty for perjury. DATE SIGNED: Signature Print Name and Title Name of Financial Institution Address and Telephone Number Note: This document must be signed by an officer or person authorized to certify the accounts at the institution. Page 1 Form 9.180.3 DEPOSITORY CERTIFICATION OF FUNDS ON DEPOSIT UTCR 9.180 (8-1-13)