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Fill and Sign the Investment Certification New Hampshire Judicial Branch Form

Fill and Sign the Investment Certification New Hampshire Judicial Branch Form

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NHJB-2167-P (07/01/2011) Page 1 of 1 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) INVESTMENT CERTIFICATION I, , (Name) (Official capacity or position) of , , (Name of Institution) (Address of Institution) do hereby certify and attest that in accordance with the decree of the County Probate Division dated , the following deposits/investments were made by , as guardian of (Guardian name) (Ward name) Form of Deposit/ Account or Date of Deposit/ Investment Certificate Number Investment Amount $ $ $ I further certify and attest that the foregoing deposits/inve stments have been restricted with notation recited on its/their face, that no withdraw al, encumbrance or other disposition may be made without express written court order ; and a copy of the referenced cour t decree has been made part of the investment records. My telephone number is . Date Signature of official State of , County of This instrument was ack nowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title

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