Form Sm-4 - Surface Mining Savings Account Assignment - Washington Department Of Natural Resources
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1SURFACE MINING
SAVINGS ACCOUNT ASSIGNMENT
(Form SM-4)
I . Fo r v a l u e r e c e i v e d , ______________________________________________, A s s i g n o r, d o e s h e r e b y a s s i g n , t r a n s f e r, a n d s e t o v e r t o t h e S t a t e
of Washington, Department of Natural Resources, hereafter called the State, all rights, title, and interest in the Assignor’s Savings
Account No. _______________________________ deposited in the ________________________________________________________ Branch
of _______________________________________________________________________________________, a financial institution authorized
to do business in the State of Washington, hereafter called the Bank, which Bank is a member of the Federal Deposit Insurance
Corporation, the Federal Savings and Loan Insurance Corporation, or the National Credit Union Administration, in the amount of
___________________________________________________________________________ dollars ($_____________________________).
70-0
II. The Assignor makes this assignment pursuant to RCW 78.44, and that certain Reclamation Permit No. _______________________ was
issued to _____________________________________________________________________________________ on _________________________.
III. The State may, at any time after giving written notice to the Assignor, demand payment from the Bank holding the above Savings
Account of an amount not to exceed _______________________________________________________ dollars ($__________________________)
plus any interest accrued from the date that the account is opened.
IV. Any penalty suffered by the State as a result of demanding payment from the Bank shall be assessed against the Assignor.
V. The Assignor is not entitled to any earnings or interest on the cash proceeds after the State has withdrawn such proceeds in the amount
as above specified from the herein described Savings Account. Such earnings and interest shall be retained by the State.
VI. The passbook to the above-mentioned Savings Account shall be held by the State during the term of the assignment.
VII. The Assignor hereby authorizes and directs the Bank to pay all or any part of the above-described deposit account including any interest
accrued from the date that the account is opened as instructed by the State until such time as the Bank shall receive the Release provided
for below. The Bank shall not be liable to inquire whether there has been performance by [the] Assignor or notice has been given As-
signor or to see to the application of any monies paid on the instruction of the State, and in such matters the Bank may rely upon the in-
struction of the State executed over the signature of the person, or his designee, appearing under the Acceptance below without need to
verify the authority of such person. Nothing herein shall prevent the State from designating a person authorized to act for it in another
lawful manner.
VIII. It is agreed, as between the Bank and the Assignor, that in the event the Bank closes or goes into receivership, any Federal Deposit
Insurance Corporation, Federal Savings and Loan Insurance Corporation, or National Credit Union Administration Insurance proceeds
paid on, to, or as a result of the Assignor deposits with said Banks, shall first be applied to cover this assignment.
IX. Signed and dated at _________________________________________, Washington, this ________ day of _______________________, _________.
Assignor’s signature
Mailing address
Printed name
BANK ACCEPTANCE
X. The _________________________________________________ Bank, as witnessed below by the signature of a duly authorized officer hereby
recognizes the above assignment of Savings Account No. ________________________________ in the amount of $ ___________________
this _____________ day of _______________________, ____________.
__________________________________________________________
Phone number
Authorized signature
Facsimile (FAX) number
Printed name
Mailing address
Branch
DEPARTMENT OF NATURAL RESOURCES ACCEPTANCE
XI. The State of Washington, Depar tment of Natural Resources, hereby accepts the foregoing assignment of Savings Account No.
___________________________ held by _________________________________________________ in the amount of _______________________
this _________ day of _____________________, ________________.
Authorized signature
RELEASE
XII. The above assignment of Savings Account No. ________________________ drawn on __________________________________________
Bank in the amount of $______________________ is hereby released. The authorized signature and seal, below, shall witness the
termination of the State’s interest in this assignment.
Authorized signature
XIII. I, ____________________________________________, Assignor in the above agreement, recognize by my signature below the release of the
assignment carried out in Clause IX above.
Signed this ________ day of ________________________, _______.
Assignor’s signature
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___________________
Reclamation Permit No.
Savings Account Assignment (Form SM-4)
Revised 12/03
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