Fill and Sign the Council Packet 04212009 City of Kirkland Form

JDF 867 SC R6/19 ACKNOWLEDGMENT OF DEPOSIT OF FUNDS TO RESTRICTED ACCOUNT Page 1 of 2 ❑ District Court ❑ Denver Probate Court __________________ County, Colorado Court Address: In the Int erest of: Protected Person /Minor COURT USE ONLY Attorney or Party W ithout Attorney (Name and Address): Phone Number: E -mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom ACKNOWLEDGMENT OF DEPOSIT OF FUNDS TO RESTRICTED ACCOUNT ______________________________ _____ _______ (name of financial institution ), acknowledge s that funds have been deposited by ____________________ (fiduciary) as the ❑ Conservator , ❑ Guardian, ❑ Next Friend , or ❑ Parent for ___________________________ ( Protected Person or M inor ) as follows: Title of Account Account Number - last 4 - digits only Amount $ Total $ ❑ By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. ❑ By checking this box, I am acknowledging that I have made a change to the original content of this form. This institution submits itself to the jurisdiction of t his court and agrees that it will not permit any withdrawal of funds except upon being furnished a certified copy of an order of this court authorizing such withdrawal. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of ___________, _________, (date) (month) (year) at ______________________________________ (city or other location, and state OR country) JDF 867 SC R6/19 ACKNOWLEDGMENT OF DEPOSIT OF FUNDS TO RESTRICTED ACCOUNT Page 2 of 2 _______________________________ (printed name of Authorized Bank Officer ) _______________________________ (signature of Authorized Bank Officer ) Type or print the Bank’s name, address and telephone number below _______________________________________________ _____________________ __________________________ _______________________________________________ Note: • Return to the Court name and address as shown above.