Ind. R. Att'y Trust Acct. B
Name of Attorney Attorney Number
Name of Law Firm
Business Address
City State Zip Code
Name of Financial Institution
Business Address
City State Zip Code
Name of Account
______________________________ _______ New _______ Existing
Account Number
Type of Account:
____ Trust ____ Guardian
____ Escrow ____ Estate
____ Other__________________________________________
(Please Describe)
The undersigned hereby certifies that he/she is an attorney licensed to practice law in the State of Indiana and that the information indicated above provided to his/her financial institution is accurate. This information is provided to permit the financial institution to report all overdraft or insufficient funds occurrences to the Indiana Supreme Court Disciplinary Commission pursuant to Indiana Admission and Discipline Rule 23, Section 29.
Date: ______________ __________________________________________________
Signature
Ind. R. Att'y Trust Acct. B