Account Registration Form - Office Of The Treasurer Of Indiana

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Account Registration Form
The undersigned officer specified in IC §5-13-9-1 of a unit of government of the State of Indiana
(the “Participant”), does hereby request that the Treasurer of the State of Indiana (the “Treasurer”)
establish an account for the benefit of the Participant within the local government investment pool (the
“Pool”) established pursuant to IC §5-13-9-11(b). By executing and delivering this Account Registration
Form and the accompanying Data Form, the Participant agrees that the account so established will be
subject to and bound by the policies established from time to time by the Treasurer pursuant to IC §5-
13-9-11(g).
The undersigned hereby certifies that the undersigned is the officer of the Participant authorized
by IC §5-13-9-11(c) to pay the funds of the Participant into the Pool and agrees to notify in writing the
Administrator of the Pool designated by the Treasurer if such officer shall change.
Participant Execution Date: __/__/____
By:
Name:
Title:
Note: All completed forms can be sent by email to clientservices@trustindiana.in.gov or by fax to 888-860-0963.
T 888-860-6242
clientservices@trustindiana.in.gov
F 888-860-0963

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