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 |