E126 (Rev. 2020-03-02)
ARIZONA DEPARTMENT OF INSURANCE SECURITY RELEASE FORM
You must complete this form to withdraw securities from Union Bank. Select one Reason for Release
Request at the bottom of the form. For Excess/Partial or Substitution release transactions, requests are
processed after Account Value is confirmed. Please contact Union Bank if you have any questions.
MAIL
MUFG Union Bank, N.A.
350 California Street, 17th Floor
San Francisco, CA 94104
FAX
(877) 833-8854
EMAIL
Arizona-Union@unionbank.com
PHONE
(800) 962-1784
Union Bank
Account Name:
Union Bank Account Number:
Company Contact: Company Contact Telephone:
Type of Release Requested (check method of delivery and complete detail on security)
Federal Reserve Security DTCC Eligible Security
For Federal Reserve securities or DTCC Eligible
securities, provide asset detail information
below:
Amount of Par To be Released:
Security Name:
CUSIP:
Security Issue Date:
Security Rate: Security Maturity Date:
DTCC Delivery Instructions: Federal Reserv
e Delivery Instructions:
Participant ID
Bank Name
Agent ID
ABA
Institutional ID For Credit to
Account Number For Further Credit to
REASON FOR RELEASE REQUEST- check one
Total Release – Request to withdraw all securities in the account (See Note below)
Excess/Partial Release – Request to withdraw funds in excess of required Minimum Account Balance
Substitution Release – Request to replace an existing security with another security.
Note: A Total Release requires prior approval from the Arizona Department of Insurance.
If we have not received their prior approval, your request will be forwarded to them.
Authorized Signature on File with Union Bank Printed Name & Title Date
