Instructions
Clear Form
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)
, County
do hereby certify and attest that in accordance with the decree of the Probate Court dated
(Guardian name)
, the following deposits/investments were made by , as guardian of
(Ward name)
Form of Deposit/ Investment
Account or Certificate Number
Date of Deposit/ Investment $ $ $
Amount
I further certify and attest that the foregoing deposits/investments have been restricted with notation recited on its/their face, that no withdrawal, encumbrance or other disposition may be made without express written court order; and a copy of the referenced court decree has been made part of the investment records. My telephone number is
.
Date
Signature of official
State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any
, County of by
Signature of Notarial Officer / Title
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NHJB-2167-P (10/01/2006) (formerly AOC-213-003) Page 1 of 1