Fiduciary Account Set-up
Date:
Name of the account:
Purpose of the account:
Source of funds received:
Use of funds:
Account Custodian:
Primary's name:
Primary's signature: _____________________________________ Date: ______________
Secondary's name:
Secondary's signature: __________________________________ Date: ______________
Please submit to Vice President of Administrative Services (Room A-102) for approval.
Approved by: __________________________________________ Date: ______________
Mailbox/Office#:
Mailbox/Office#:
Phone#:
Phone#:
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