TOS 0004 rev 10-2000
CUSTODIAL ACCOUNT WITHDRAWAL
Authorized Signature
Title
Date Completed
Completed By
Agency Name Date
Agency Remit. No. Acct. No. Agency No. Acct No.
Account Title
Custodial Account
Agency Remit. No.
Treasury Contingency Account
Withdrawal of Funds From:
Total
Payee and Address Purpose for Withdrawal/Memo
Amount
Ck./Transfer No.
0.00
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$ 0.00
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