Form Sm-5 - Surface Mining Savings Certificate Assignment - Washington State Department Of Natural Resources
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1SURFACE MINING SAVINGS
CERTIFICATE ASSIGNMENT
(Form SM-5)
I. For value received, ______________________________________________, Assignor, does hereby assign, transfer, and set over to the State of
Washington, Department of Natural Resources, hereafter called the State, all rights, title, and interest in Savings Certificate No.
_________________________________ in the amount of ____________________________________________________________________ dollars
($_________________________________), payable on or after ___________________________________________________________ , issued by
__________________________________________________________________________________________________________________________,
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, and payable to _______________________________________________________________________, the Assignor herein.
II. The Assignor makes this assignment pursuant to RCW 78.44, and that certain Reclamation Permit No. ________________________ was
issued to __________________________________________________________________________________ on ____________________, ________.
III. The Assignor may, with the consent of the State, replace or renew a Savings Ceritificate once it has expired or is voided by the Bank.
IV. The State may at any time, after giving written notice to the Assignor, surrender the Savings Certificate to the Bank in exchange for
money.
V. Any penalty suffered by the State as a result of demanding payment from the Bank shall be assessed against the Assignor.
VI. The Assignor is not entitled to any earnings or interest on the cash proceeds after the State has surrendered the Savings Certificate. Such
earnings and interest shall be retained by the State.
VII. The Savings Certificate shall be held by the State during the term of this assignment.
VIII. The Assignor hereby authorizes and directs the Bank to pay the above-described Savings Certificate or any interest or earnings thereof
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 the Assignor 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 instruction 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.
IX. 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.
X.
Signed and dated at ___________________________________________, Washington, this ________ day of ____________________________.
Assignor’s signature
Mailing address
Printed name
BANK ACCEPTANCE
XI. The _______________________________________________________________________ Bank, as witnessed below by the signature of a duly
authorized officer hereby recognizes the above assignment of Savings Certificate No. ________________________________ in the amount
of $__________________________________ this _________ day of _______________________, _________.
______________________________
Phone
Authorized signature
Mailing address
Printed name
Branch
DEPARTMENT OF NATURAL RESOURCES ACCEPTANCE
XII. The State of Washington, Department of Natural Resources, hereby accepts the foregoing assignment of Savings Certificate No.
_________________________ held by ______________________________________________________ in the amount of $ ___________________
this _______ day of ___________________________, _____________.
Authorized signature
RELEASE
XIII. The above assignment of Savings Certificate No. _________________________ drawn on ________________________________________
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
XIV. I, ____________________________________________, Assignor in the above agreement, recognize by my signature below the release of the
assignment as carried out in Clause X above.
Signed this ________ day of __________________________, _________.
___________________________________________________________
Assignor’s signature
___________________
Reclamation Permit No.
Savings Certificate Assignment (Form SM-5)
Revised 1/01
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