Affidavit And Acknowledgment Of Restriction Form
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1IN THE CIRCUIT COURT OF THE STATE OF OREGON
THIRD JUDICIAL DISTRICT
Probate Department
In the Matter of the:
)
)
Case No.
Conservatorship
UTMA Account of:
)
)
AFFIDAVIT AND
_____________________________________ )
ACKNOWLEDGMENT OF
A Protected Person. )
RESTRICTION
STATE OF OREGON
)
)
ss.
County of ______________
)
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:
________________________
Dividends/interest income are:
Account balance:
$_______________________
Reinvested/remain in the account
Share value:
$_______________________
Other: _____________________
Number of shares: ________________________
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:___________________________
___________________________________
Name of Financial Institution
By:_________________________________
*NOTE: THIS AFFIDAVIT MUST BE SIGNED BY
Title: ______________________________
THE BRANCH MANAGER OR EQUIVALENT
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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