Fillable Form 847d - Operator Assignment Of Cash Deposit printable pdf download

Form 847d - Operator Assignment Of Cash Deposit

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Alaska

847D

Operator Assignment of Cash Deposit

AS 05.15.122. For value received, the undersigned hereby assigns and transfers unto the State of Alaska, the annexed

#, _______________________________________________

__________________________

TCDS

in the amount of $

Issued by:

Bank Name

Address

City, State, Zip Code

Bank Phone Number

for the Games of Chance and Skill operator security as required by the laws of the State of Alaska for licensing of:

as an operator, doing business as

who is an:

Individual

Qualified Organization

Municipality

The undersigned does hereby irrevocably constitute and appoint the State of Alaska by and through its duly authorized agents as their Attorney-in-Fact

to do all things necessary and appropriate to effectuate the purposes of this assignment.

It is agreed and understood that this assignment shall remain in full force and effect for the period of time provided by law for actions against the said

security.

Dated at

Alaska, This

day of

, 20

The person whose name appears on Certificate of Deposit must sign below:

Applicant’s Signature

Social Security Number

STATE OF ALASKA

)

ss:

JUDICIAL DISTRICT

)

This is to certify that on this

day of

, before me, the undersigned, notary public in and for the State of Alaska, duly

commissioned and sworn, personally appeared

to me known to be the person

described in and who executed the above and foregoing Assignment of Cash Deposit, and he/she acknowledged to me that he/she signed and sealed

the same freely and voluntarily for uses and purposes therein mentioned.

WITNESS my hand and official seal the day and year in this certificate first above written.

Notary Public for the State of Alaska

_________________________

My Commission Expires:

By signature below, the issuing institution agrees that only the State of Alaska, upon presentation of written notice, shall cause the release of any and

all funds described above.

Bank Representative

Date

Phone (907) 465-2320

Fax (907) 465-3098

847D

Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420

0405-847D Rev 04/19/13