Pbb Form 4 - Control Agreement - Single Owner Page 4
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4FINANCIAL INSTITUTION:
_______________________________
a ______________________________
By: ________________________________________________
Name: ______________________________________________
Title: _______________________________________________
Address: ____________________________________________
___________________________________________________
STATE OF VIRGINIA
CITY/COUNTY OF __________________, to wit:
The foregoing Control Agreement was acknowledged before me this ______day of ___________________, 20___ by
___________________________________ acting in his/her capacity as ___________________________ of
_________________________________________ on behalf of the Bank.
My commission expires:
Notary Public
COMMONWEALTH OF VIRGINIA:
COMMONWEALTH OF VIRGINIA, DEPARTMENT
OF CRIMINAL JUSTICE SERVICES
By: ________________________________________________
Name: ______________________________________________
Title: _______________________________________________
Address: ____________________________________________
___________________________________________________
STATE OF VIRGINIA
CITY/COUNTY OF __________________, to wit:
The foregoing Control Agreement was acknowledged before me this ______day of ___________________, 20___ by
___________________________________ acting in his/her capacity as ___________________________ of the
Commonwealth of Virginia, Department of Criminal Justice Services on behalf of the Department.
My commission expires:
Notary Public
DCJS Control Agreement – Single Owner, PBB Form #4
Updated: 09/2014
Page 4 of 4
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