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NOTE: Use the certificates on this page to verify balances in each account held OR attach copies of bank statements for each

account showing balances on ending date.

CERTIFICATE OF BALANCES ON DEPOSIT

____________________________________________________________________________________________________________________________

(Name and Address of Financial Institution)

I do certify that on _________________________, 20_________, there was on deposit in this institution to the credit of the estate managed by this

Fiduciary the following:

Checking Account Balance: $___________________________________Savings Account Balance $_________________________________________

Certificate(s) of Deposit at Face Value: $_________________________________________________________________________________________

Interest paid and credited to the above accounts during period of this Statement of Account totaled $_____________________________________.

[Do NOT include accrued but unpaid interest.]

_____________________________________________________________

(Printed Name and Title of Certifying Financial Official)

_____________________________________________________________

Financial Institution Stamp or Seal

(Signature of Certifying Financial Official)

CERTIFICATE OF BALANCES ON DEPOSIT

____________________________________________________________________________________________________________________________

(Name and Address of Financial Institution)

I do certify that on _________________________, 20_________, there was on deposit in this institution to the credit of the estate managed by this

Fiduciary the following:

Checking Account Balance: $___________________________________Savings Account Balance $_________________________________________

Certificate(s) of Deposit at Face Value: $_________________________________________________________________________________________

Interest paid and credited to the above accounts during period of this Statement of Account totaled $_____________________________________.

[Do NOT include accrued but unpaid interest.]

_____________________________________________________________

(Printed Name and Title of Certifying Financial Official)

_____________________________________________________________

Financial Institution Stamp or Seal

(Signature of Certifying Financial Official)

[NOTE: Please copy this page if additional certificates are needed.]

NOTE: The following affidavit must be completed by the Administrator or Executor (or the Attorney for the Administrator or

Executor) of the estate of a decedent who is required by law or court order to file returns:

Affidavit of Service of Copies for Decedent’s Estate

I (we) certify that I (we) have this date delivered in person or by first-class mail a true and correct copy of the attached Annual/Final return

filed for the Estate of ______________________________________________, decedent, to each [beneficiary of the testate estate] [heir of the

intestate estate] as required by law, except to each of the following who have delivered to me (us) a written waiver of the right to receive such

copy, which waiver has not been revoked: _____________________________________________________________________________________.

Sworn to and subscribed before me on

____________________________________________________

_________________________, 20_______.

ADMINISTRATOR / EXECUTOR / ATTORNEY

____________________________________

____________________________________________________

CLERK of Probate Court / Notary Public

ADMINISTRATOR / EXECUTOR / ATTORNEY

Certificate Of Balances On Deposit And Affidavit Of Service Of Copies For Decedent'S Estate - Henry County Probate Court

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