Free Affidavit and Acknowledgment of Restriction - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON THIRD JUDICIAL DISTRICT Probate Department ) ) Conservatorship UTMA Account of: ) ) _____________________________________ ) A Protected Person. ) STATE OF OREGON County of ______________ ) ) ) In the Matter of the:

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)