Fillable Electronic Warrant - Account Transfer Form printable pdf download

Electronic Warrant - Account Transfer Form

Download a blank fillable Electronic Warrant - Account Transfer Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Electronic Warrant - Account Transfer Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

TEMPLATE FORM

CB$ ELECTRONIC WARRANT – ACCOUNT TRANSFER

Revised 02/2016

(To be used to establish a template for a repetitive account transfer via CB$)

To:

From:

(

)

Agency Name and Address

Date: ______________________

Department of State Treasurer

Banking Operations Section

Email:

Pursuant to the State Treasurer’s established procedures for the use of Electronic Warrants, this is to request the establishment

(or

deletion/change) of a repetitive template number. The requested preauthorized payment is not eligible to be made via OSC’s CMCS. It

is a payment either to: 1) CIT account at Department of Revenue; 2) CIT account at Retirement Systems Division; 3) CIT account

within the agency; or 4) STIF account within the agency.

TYPE OF REQUEST

___ Add ____ Delete

____ Change (If Delete or Change, current Template No. ________________)

DEBIT INFORMATION (Source Account):

DSB/ STIF Acct. Number: __- __ __ __-__ __ __

Account Name: __________________________________________

TYPE OF PAYMENT (Product Code):

___ FT3T – DOR Tax Pym: Tax ID#:_______________

_____FT3R – Retirement Contribution Payment: Unit#:__________

____ FT3C – CIT Account Transfer ____ FT3S – STIF Account Transfer

____ FT3C – Other Account Transfer

DESIGNATION (Credit) ACCOUNT

Acct Number: _____________________________________________

Acct Name: _________________________________

Agency Name: __________________________________________________

Payment Details (Description) ___________________________________________________________________________________

JUSTIFICATION FOR REQUEST:

REQUEST / PREAUTHORIZATION SUBMITTED BY:

Agency Name: ________________________________________

CB$ Agency ID: ____________

(XXXNNNN Characters)

Printed Name & Title: _____________________________________________

Signature: _____________________________________

(Must be on signature card)

Phone Number: ____________________________

Fax Number: __________________________

FOR STATE TREASURER’S USE ONLY (Complete If Approved):

Template No. Assigned: _____________

____ Template setup/modified on CB$

____ Signature card verified

By: _____________________________________________ Date: ________________

Setup/Modification Reviewed By: _____________________________________________ Date: ________________

If request is approved by State Treasurer, a copy of this form will be returned to the Agency’s Chief Fiscal Officer.

All agency CB$ users granted the Funds Transfer role, and mapped to the associated account, will be able to initiate/authorize electronic warrants for the template.

Electronic Warrant - Account Transfer Form

Related Articles

Related forms

Related Categories