STATE OF MICHIGAN

PROBATE COURT
COUNTY

PROOF OF RESTRICTED ACCOUNT AND 
ANNUAL VERIFICATION OF
FUNDS ON DEPOSIT
(CONSERVATORSHIP OF MINOR)

CASE NO. and JUDGE

Court address              

 

 

 

Court telephone no.

In the matter of 

First, middle, and last name of the minor

USE NOTE: This form must be completed and filed with the court within 28 days of the conservator’s qualification, or as 
otherwise ordered by the court, and annually thereafter.

Name of financial institution/insurance company/brokerage firm

Address

Telephone no.

Name of authorized representative

Title

I certify that the estate funds of the minor are currently on deposit with us under a restricted account as follows:

Type of account

Last 4 digits of account no.

Balance

Account caption (include name of conservator)

A copy of the corresponding financial institution’s statement accompanies this proof of restricted account.*

I further certify that

1. The funds, including accruals, shall not be released or withdrawn except by written order of this court.

2. Records have been marked to prohibit withdrawal except by written order of this court.

3. We are liable for funds released or withdrawn without written order of this court.

Date

 

Signature of authorized representative

*For annual verification, the corresponding financial institution’s statement must be dated within 30 days after the end of the
 annual accounting period.

Approved, SCAO
Form PC 669, Rev. 1/21
MCR 5.409(C)(4)
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JIS Code: PAR/VFD