Adapted from National Guardianship Association form.
Date: _____/_____/_____
Incapacitated Person's Name:
We are in the process of determining the assets for the above mentioned. We are requesting the following information be completed for all accounts that may be held with your institution. A self-addressed envelope is enclosed for your reply.
Banking Institution: Bank Address:
Checking and Savings Account(s)
| Type of Account | | | | |
|---|
| Account Number | | | | |
|---|
| Titling of Account | | | | |
|---|
| Date Opened | | | | |
|---|
| Date Closed | | | | |
|---|
| Closed by Whom | | | | |
|---|
| Interest Rate | | | | |
|---|
| Balance as of / / | | | | |
|---|
Are there any Direct Deposits being made to the above account(s)? If so, which one(s) and from where?
Safe Deposit Box
| Box Number & Titling of Box | | |
|---|
| Date Opened | | |
|---|
| Date Closed | | |
|---|
| Closed by Whom | | |
|---|
Certificates of Deposits
| Certificate Number & Titling
of Certificate | | |
|---|
| Date Opened | | |
|---|
| Maturity Date | | |
|---|
| Closed by Whom | | |
|---|
| Balance as of / / | | |
|---|
| Term of CD & Rate | | |
|---|