State Form 44746 (R4 / 9-15)
Approved by State Board of Accounts, 2015
One North Capitol Avenue, Suite 600
Indianapolis, Indiana 46204
Telephone: (317) 232-1360
Fax: (317) 232-1362
Name of bank Telephone number
( )
Address (number and street, city, state, and ZIP code)
Account number Taxpayer identification number
Title of account
Name of company
Address (number and street, city, state, and ZIP code)
I, the undersigned, hereby certify that I am the __________________________________________________________________________________
(Business title)
of _____________________________________________________________________________________________________________________
(Name of business, if incorporation give full corporate name.)
(“this Company”); that I am the keeper of the records of this company and that as such, I am authorized to execute this certification on behalf of this
It is agreed on behalf of this company:
that $_______________________________________________ (the “Funds”) be delivered to the Indiana Grain Buyers and Warehouse Licensing
Agency (the “Agency”) as a cash deposit in accordance with rules .and regulations of the Agency;
that ____________________________________________________________________________________________________________________
(Name of bank)
(the “Bank”) is hereby designated as a depository for the Funds, and that an account be established by the Agency with the Bank on behalf of this
that the Bank is authorized to accept the taxpayer Identification number of this Company and to report to the Internal Revenue Service or other
governmental authority, any interest earned on the account under the tax identification number;
that the account and the Funds, including any accrued interest, shall be under the control of the Agency, and the Bank is authorized to act on the
directions and instructions of the Agency in establishing the account, accumulation of income, closing of the account, and payment of the proceeds to
any person; and
that the Bank shall be entitled to conclusively assume that this authority remains in full force and effect, and that all powers and authorities permitted by
the authority have been and continue to be in effect, except and until the Agency advised the Bank to the contrary in writing.
I do further certify that this Company is in good standing in all jurisdictions in which it is required to be qualified to do business and that the execution of
the Agreements authorized hereunder is no violation of the charter by-laws or agreements of this Company.
In witness whereof, I have hereunto subscribed my name this date (month, day, year): ___________________________________________________
Signature Title
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