Form Dos-255 - Games Of Chance Registration - Nys Department Of State Page 4
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1
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5ACCOUNT
DATE
NYS DEPARTMENT OF STATE
BALANCE
MISCELLANEOUS RECORDS BUREAU
$
ONE COMMERCE PLAZA, 99 WASHINGTON AVE.
ALBANY, NY 12231-0001
Certificate of Deposit
This certificate evidences that on the _______ day of ___________, 20 ___, trust account No. ___________
was open at this bank, located at ___________________________________________________________,
The name of the account is ________________________________________________________________
_____________________________________________________________________________________ .
This certificate evidences a balance in the account as of this day in the amount shown above. Funds cannot be
withdrawn from this account without certification to the Secretary of State of the State of New York.
Bank ___________________________________
By ___________________________________
Cashier
Sworn to before me this _________ day of
___________________ , 20 _____.
___________________________
Notary Public
DOS-260 (Rev. 11/99)
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