LGIP INFORMATION CHANGE FORM

RESET FORM
INFORMATION CHANGE FORM
STATE OF TENNESSEE LOCAL GOVERNMENT INVESTMENT POOL
Complete appropriate sections of form. Put N/A for sections that are not applicable to your change. Send to: Local
Government Investment Pool, P.O. Box 198785, Nashville, TN 37219-0505.
1. LGIP Participant and Account #: ___________________________________________________________________
2. LGIP Entity Name: ____________________________________
4. Phone #: _______________________
3. Contact Person: ________________________
5. Fax #: _____________________
6. Date: _______________________
MEMBERSHIP DATA
Current
7. Entity Name:
Change To
___________________________________
____________________________________
8. Account Name: ___________________________________
____________________________________
9. Address:
___________________________________
____________________________________
10. Phone #:
___________________________________
____________________________________
11. FAX #:
___________________________________
____________________________________
PERSONS TO CONDUCT LGIP TRANSACTIONS
(Typed/Printed) Name
Signature
Title
12. Add:
__________________________
__________________________
________________________
13.
__________________________
__________________________
________________________
14.
__________________________
__________________________
________________________
(Typed/Printed) Name
Title
15. Delete:
______________________________________
_______________________________________
16.
______________________________________
_______________________________________
17.
______________________________________
_______________________________________
BANK INFORMATION (Attach deposit slip for each added bank account.)
Bank Name and Address
18. Add:
__________________________
Account # and Bank T/R#
Name of Bank Account
__________________________
________________________
__________________________
________________________
__________________________
________________________
__________________________
19.
__________________________
__________________________
20.
__________________________
__________________________
TR-0308 (3/06)
Appendix B-1
RDA 2126
INFORMATION CHANGE FORM
21. Delete:
Bank Name and Address
Account # and Bank T/R#
Name of Bank Account
__________________________
__________________________
________________________
__________________________
________________________
__________________________
________________________
__________________________
22.
__________________________
__________________________
23.
__________________________
__________________________
AUTHORIZED OFFICER(S)
The following individuals are now the authorized financial officer(s) charged with the custody of the funds to participate in
the LGIP:
(Typed/Printed) Name
Signature
Title
24.
__________________________
__________________________
________________________
25.
__________________________
__________________________
________________________
NOTARIZATION
26. BY:
___________________________________
Authorized Officer
27.
___________________________________
Typed/Printed Name
28.
___________________________________
Title
29. STATE OF TENNESSEE, COUNTY OF _______________________
Sworn and subscribed to me on this the _______ day of ______________________, _________.
________________________________
Date My Commission Expires
____________________________
Notary Public Signature
SEAL
Appendix B-2
INFORMATION CHANGE FORM INSTRUCTIONS
Return this change form to LGIP Office, P.O. Box190505, Nashville, TN 37219-8785. Please keep a copy for your records.
Complete the blank lines on the change form as follows:
1. LGIP Participant and Account Number are the numbers that were assigned to you for LGIP transactions. The participant number
is a six digit number. If needed, please also include the sub-account number you wish to change as well (Ex. 555555 - 10). If all
accounts are to reflect the changes, you may list them individually or state “all” accounts (Ex. 555555 - 1,2,3,4, and 10 OR
555555 - ALL).
2. LGIP Entity Name is the name of your governmental entity (local government or political subdivision).
3. The contact person is the person responsible for the day-to-day responsibilities concerning the LGIP account.
4. Phone number is the number at which LGIP can contact you if needed. Please include area code as well.
5. Fax number is the number to which LGIP may fax correspondance to you if needed. Please include area code as well.
6. Date is the current date on which the form is completed.
For items 7 through 11, please provide the old data for reference as well as the new data you want to authorize.
7. Entity Name is the name of your local government or political subdivision.
8. Account Name is the name under which the governmental entity wishes the LGIP to carry its account.
9. Address is the mailing address where you want your LGIP correspondence directed. Please include street or post office box
number, city, state, and zip code.
10. Phone Number is the telephone number where a person authorized by your governmental entity to perform LGIP transactions
can be reached.
11. FAX Number is the telephone number of a facsimile copy machine that is convenient to your governmental entity personnel
authorized to do business with LGIP. Insert “N/A” if this does not apply to you.
For items 12 through 23, please indicate only the information that you want added and/or deleted.
12. Persons who will conduct LGIP transactions may be added by inserting their typed/printed name, and affixing an original
signature and current job title on the indicated blanks on items 11 through 13.
15. Persons who will conduct LGIP transactions may be removed by inserting their typed/printed name(s) and job title(s) on lines
14 through 16.
18. If you wish to add a bank account to be authorized to receive funds from your LGIP account, insert the bank name, address,
account number and transit routing number, and name of account. (Name of account if the name under which this bank account is
held.) Attach a bank account deposit form for each account you wish to add.
21. To remove a bank account from the list of bank accounts authorized to receive funds from your LGIP account, provide the bank
name, address, account number and bank transit routing number, and name of account.
Please provide all data requested in items 24 through 29.
24. Authorized Officers are those individuals or officers charged by the governing body of your county or political subdivision with
custody of the funds associated with this LGIP account. Please provide the typedor printed name, original signature and title of
those individuals who are charged with the responsibility of the funds source to this LGIP account.
26. Authorized Officer is the individual who is responsible for these funds and responsible for designating how transactions will be
authorized. Please provide an original signature.
27. Please type or print the name of the individual whose signature appears on line 25.
28. Please provide the title of the individual who signed on line 25.
29. The notary statement, signature and seal is to be completed by a Tennessee notary. Please provide notarization of all change forms.
Any questions about this change form may be addressed to the LGIP staff at (615) 532-1163.
Appendix B-3