Form E150 - Assignment To Arizona State Treasurer Security In Lieu Of Cash Deposit
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1Department of Insurance
State of Arizona
Financial Affairs Division Trust Deposit Unit
2910 North 44th Street, Suite 210
Phoenix, Arizona 85018-7269
Telephone: (602) 364-2712
Fax: (602) 364-3989
Assignment to Arizona State Treasurer Security in Lieu of Cash Deposit
Prepare in duplicate. Please type all information. Attach 2 original Assignments to Certificate of Deposit to be filed with State.
Circle Deposit Type:
Ordinary
Security Deposit
Retaliatory
HCSO Escrow Reserve
Workers’ Compensation
COMPANY NAME
STATE OF INCORPORATION
STREET ADDRESS
CITY
STATE
ZIP
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
NAME OF FINANCIAL INSTITUTION
as evidenced by an account in the amount of
dollars
($__________________)
identified by Certificate of Deposit number _____________________, held in account number __________________, which account is
Federally insured by ____________________________________.
This assignment is given as security for authority to transact
insurance or related business/service regulated by the Department of Insurance in the State of Arizona.
Dated this ____________ day of ______________________________, at
IMPORTANT - SIGNATURE OF ASSIGNOR:
TYPE NAME OF AUTHORIZED OFFICER
BY:
SIGNATURE OF AUTHORIZED OFFICER OF COMPANY
TYPE TITLE OF OFFICER
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 laws applicable to this institution.
Dated this ____________ day of ______________________________, _________, at
, Arizona.
NAME OF FINANCIAL INSTITUTION
STREET ADDRESS
CITY
STATE
ZIP
BY:
SIGNATURE OF OFFICER OF FINANCIAL INSTITUTION
TYPE NAME AND TITLE OF OFFICER
Subscribed and sworn before me this ________ day of __________________________ 20_____.
COMMISSION EXPIRES
NOTARY PUBLIC SIGNATURE
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 to the above-named assignor.
Dated this __________________ day of _____________________, ______ at __________________________________, Arizona.
By: ___________________________________________________________________
ARIZONA STATE TREASURER or Authorized Representative
Form E150 (Rev. 12/05)
Page 1 of 1
K:\Trust Unit\Trust Deposit Forms\2005 Revised Forms\E150.doc
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