treasurer investment pool transaction

TREASURER INVESTMENT POOL
TRANSACTION AUTHORIZATION FORM
Please fill out this form completely, including any existing information, as this form will replace the previous form.
Mailing Address:
Name of Entity:
Fax Number:
E-mail Contact:
Do you wish to have your monthly TIP statements faxed or emailed?
Please note – if you choose to receive statements via fax, you will not receive another copy via U.S. mail.
YES, please fax statements
No, please send statements via U.S. mail
YES, please email statements
Bank account where funds will be wired when a withdrawal is requested.
(Note: Funds will not be transferred to any account other than that listed).
Bank Name:
Branch Location:
Bank Routing Number:
Account Number:
Account Name:
Persons authorized to make deposits and withdrawals for the entity listed above.
Name
Title
Signature
Telephone Number
By signature below, I certify I am authorized to represent the institution/agency for the purpose of this transaction.
(Authorized Signature)
(Title)
(Date)
(Print Authorized Signature)
(E-mail Address)
(Telephone number)
Any changes to these instructions must be submitted in writing to the Office of the County Treasurer. Please mail
this form to the address listed below:
KLAMATH COUNTY TREASURER
Date Received: ____ / ____ / _____
TREASURER INVESTMENT POOL
Fund Number: ____________
305 MAIN STREET
(for TIP use only)
KLAMATH FALLS, OREGON 97601
FAX: (541) 883-5165
State of Oregon )
County of
) SS.
Signed or attested before me by
.
Dated this ___ day of ___________, 20__.
Signature of Notary
SEAL OR STAMP
Typed or printed name of Notary
Notary Public in and for the State of Oregon.
My appointment expires: