Assignment To Arizona State Treasurer Form printable pdf download

ASSIGNMENT TO ARIZONA STATE TREASURER

SECURITY IN LIEU OF CASH DEPOSIT FOR COMPLIANCE WITH

SECTION 35-155 ARIZONA REVISED STATUTES

NAME

STREET ADDRESS

CITY

COUNTY

STATE

TELEPHONE NUMBER

hereinafter referred to as ASSIGNOR, does hereby assign and transfer to the Treasurer of the State of Arizona, hereinafter referred to as the

TREASURER, all right, title and interest of any kind whatsoever, owned or held by Assignor in the principal, but not in the interest hereinafter

accruing after the date of this assignment in the insured account of ASSIGNOR so long as such funds remain on deposit in the

FINANCIAL INSTITUTION

whose address is _____________________________________________________________________________________________

STREET ADDRESS

CITY

COUNTY

________________________________________________________________

Arizona, as evidenced by an account in the amount of

($____________)

_____________________________________

dollars

identified by account number

which account is insured by the Federal

Deposit Insurance Corporation or the Federal Savings and Loan Insurance Corporation. This assignment is given as security for

Dated this __________ day of ____________________, 20_____, at ______________________________ Arizona.

IMPORTANT – SIGNATURE OF ASSIGNOR

__________________________________________________

This assignment shall be signed by the

NAME OF ASSIGNOR EXACTLY AS SHOWN ABOVE

Individual Himself.

BY:

__________________________________________________

SIGNATURE OF ASSIGNOR

FIRST ENDORSEMENT – RECEIPT FOR NOTICE OF ASSIGNMENT

Receipt is hereby acknowledged to the Treasurer of the State of Arizona, hereinafter referred to as the TREASURER, of written notice of the

assignment to said Treasurer of the above-identified account. We have noted our records to show the interest of the Treasurer in said account as

shown in and by the assignment above. We have retained a copy of this document. We hereby certify that we have not received any notice of lien,

encumbrance, hold, claim or other obligation against the above-identified account prior to its assignment to the Treasurer. We further hereby waive

any current and future right of set-off against such account. We agree to make payment as required by the Rules and Regulations of the Treasurer

adopted in accordance with applicable laws and the law applicable to this institution.

Dated this __________ day of ____________________, 20_____, at ______________________________ Arizona.

NAME OF FINANCIAL INSTITUTION

____________________________________________________________________________________________________

SIGNATURE OF OFFICER OF FINANCIAL INSTITUTION

TITLE

Subscribed and sworn before me this __________ day of ____________________, 20_____.

__________________________________________________

NOTARY PUBLIC SIGNATURE

__________________________________________________

COMMISSION EXPIRES

SECOND ENDORSEMENT – RECEIPT FOR SECURITY AND DIRECTION TO PAY EARNINGS

Receipt is acknowledged of the assignment above and the account identified in the assignment above. The financial institution named in the

assignment above is hereby authorized and directed to pay any earnings credited after the date of this assignment on the above-identified account of

the above-named assignor.

Dated this __________ day of ____________________, 20_____, at ______________________________ Arizona.

ARIZONA STATE TREASURER

Treasurer or Authorized Representative

By: ______________________________

(Prepare in duplicate. Please type all information)

Attach original assignment to certificates of deposit and file with State.

Assignment To Arizona State Treasurer Form

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