Rev 12.8.2016
Authorization to Pledge / Release Securities Form
***** Reproduce on Public Depository Letterhead *****
Office of the State Treasurer
Phone: (775) 684-5610
Pooled Collateral
Fax : (775) 684-5776
101 N. Carson St.
Carson City, NV 89701
Please e-mail this form to:
Pledge Additional Securities Release Existing Securities (No Substitution)
Replace and Substitute Securities
Third Party Depository:
Public Depository:
Add Release Description of Security(Inc CUSIP) Par Value Market Value
*Attach additional sheets if necessary
Authorized Name (Please Print) Authorized Name
Public Depository State of Nevada
Authorized Signature Date Authorized Signature Date
Public Depository State of Nevada
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