Time Deposit Information Form - California State …
| |State of California Treasurer’s Office |STO 4000 |
| |Investment Division |New 1/2003 |
| |Time Deposit Information Form | |
| | | |
|In order for our office to complete your account, it is necessary that your firm provide us with the following information (Please Print/Type): |
| |
|Full Name of Financial Institution: | |Date Completed: |
| |Check One: |Bank: | |Thrift: | |Credit Union: | | |
|Charter Type: |Federal: | |State: | | |
|Primary Contact Person/Alternative: | | |
| |
|Negotiate Transactions |Primary Contact: |Secondary Contact: |
| | | |
| |Name: | | |
| | | | |
| |Title: | | |
| |
| |Address: | |
| | | | | | |
| | |(City) |(County) |(State) |(Zip Code) |
|Telephone Number: | | |
|Fax Number: | | |
|Mobile Phone Number: | | |
|Email Address: | | |
| | | | | |
| | | | | |
|Interest Payments |Primary Contact: |Secondary Contact: |
| | |
| |Name: | | |
| | | | |
| |Title: | | |
| | | | |
| |Address: | |
| | | | | | |
| | |(City) |(County) |(State) |(Zip Code) |
|Telephone Number: | | |
|Fax Number: | | |
|Mobile Phone Number: | | |
|Email Address: | | |
| | | | | |
| | | | | |
|Collateral Transfer |Primary Contact: |Secondary Contact: |
| | |
| |Name: | | |
| | | | |
| |Title: | | |
| | | | |
| |Address: | |
| | | | | | |
| | |(City) |(County) |(State) |(Zip Code) |
|Telephone Number: | | |
|Fax Number: | | |
|Mobile Phone Number: | | |
|Email Address: | | |
| | | | | |
| |
|Wire Instructions (Inst. On wiring funds to your Bank) |
| | | | | |
| |Name of Correspondent Bank: | |
| | | |
| |ABA Number: | |
| | | |
| |Account Name/Number: | |
| | | |
| |Attn: | |
| | | |
| |Further Instructions: | |
| | | |
| | | |
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|Name of Financial Institution: | |
| | |
|Company Website Address: | |
|Depositary Information – Collateral Account |
| | | |
| |Name of Depositary Bank: | |
| | | |
| |Account Number: | |
| | | |
| |Address: | |
| | | |
| | | |
| | |(City, State, Zip Code) |
| |Attn: | |
| | | |
| |Telephone Number/Fax Number: | |
| |Mobile Phone Number: | |
| |Email Address: | |
| | | |
|Other Required Contact Information |
| | | |
|Board Chairman | |
| |Name: | |
| |Address: | |
| | | |
| | | |
| | |(City, State, Zip Code) |
| |Telephone Number: | |
| |Fax Number: | |
| | | |
| |Email Address: | |
|President/CEO | |
| |Name: | |
| |Address: | |
| | | |
| | | |
| | |(City, State, Zip Code) |
| |Telephone Number: | |
| |Fax Number: | |
| | | |
| |Email Address: | |
|Chief Financial Officer | |
| |Name: | |
| |Address: | |
| | | |
| | | |
| | |(City, State, Zip Code) |
| |Telephone Number: | |
| |Fax Number: | |
| | | |
| |Email Address: | |
| | | | | |
| | |Primary Contact Name: | | |
| | | |(Please print) | |
| | | | | |
| | |Signature: | | |
| | | | | |
| | |Title: | | |
| | | | | |
| | |Date: | | |
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