Tillamook Supp. L. R. 19 app VIII

As amended through June 11, 2024

Appendix VIII - Acknowledgement of Restricted Assets

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF TILLAMOOK

In the Matter of the:____________	)
of	)	Case No.:_________________
	)
	)	ACKNOWLEDGMENT OF
[] Deceased [] Minor [] Incapacitated	)	RESTRICTION OF ASSETS
	)

We acknowledge receipt of a copy of the court order signed____________, 20_____that restricts access to the assets of the above estate/conservatorship as described below. We will not allow ANY distribution or withdrawal of principal or income from these assets or use of the assets as security for any obligation without specific authority by court order, except as allowed by this order unless modified by a subsequent order of the court. We will not close the account without court order or upon the minor reaching the age of majority. We will provide the court with at least thirty (30) days prior written notice with any intent to close for any other reason. The order allows the conservator/personal representative to make withdrawals from the restricted assets as follows: [] None [] Other (conditions or restrictions):

The assets on deposit with us that are subject to the order are identified as follows:

Account Number	Value of Account Assets	Type of Account	Maturity

(You may list any other accounts subject to the court's order on the back of this form) The name of the holder of the account shown on our records is/are:_____________________

We understand that the conservator/personal representative may do the following without court order:

Transfer restricted assets to other accounts with us that are subject to the restrictions stated above; and Change the investment of assets, as long as all assets remain in an account with us subject to the restrictions stated above.

We agree to abide by the order. We understand that if assets are removed from a restricted account without prior court order, this institution shall be required to pay the value of those assets to the estate/ conservatorship.

DATED:__________________, 20________	Name and address of Financial Institution:
	__________________________
THIS DOCUMENT MUST BE SIGNED BY AN OFFICER OR OTHER PERSON	__________________________
AUTHORIZED TO BIND THE INSTITUTION	__________________________
	By:__________________
	__________________________ Printed Name and Title

Tillamook Supp. L. R. 19 app VIII

Amended effective 2/1/2024.