in the court of common pleas of lehigh county, pennsylvania

orphans’ court division

IN RE:	:
:	File No.
A Minor	:

CERTIFICATION OF PARENT/GUARDIAN/LEGAL CUSTODIAN REGARDING COURT ESTABLISHED RESTRICTED BANK ACCOUNT FOR MINOR

I,	, certify that:
1.	I am the mother father / other	of
(describe relationship to minor)
, a minor, and the petitioner for court approval of the
compromise and distribution of funds payable to said minor filed to No.
in the Civil Division Orphans' Court Division of this Court.
2.	Pursuant to Court Order dated	the sum of
was deposited by	Esquire, in an insured,
interest bearing Savings Account, Certificate of Deposit in the name of
“	“, a minor at
Bank located at

3.	I understand that it is my responsibility to inform the bank in which the minor's restricted
account has been established if any of the following events occur during the minority of
so that the bank can continue to provide statements
to me regarding the minor's restricted account:
The name[s] and/or address[es] of either or both of the minor's custodial parent[s] change[s].

The minor's name and/or address changes.

The parent with legal custody of the minor changes.
4.	I understand that it is my responsibility to remain aware of any changes to the name of the
bank that may occur (by reason of merger or otherwise) during the minority of
.
5.	I understand that it is my responsibility to retain the documentation of the establishment
of the restricted account for	a minor, including a
copy of the court order, the affidavit of deposit and the certificate of deposit or opening
statement.

Name	Signature
(Please type)
Address
Phone No.

2

IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA

Rachel A Wotring

2023-12-01

County of Lehigh