Form E150 (v. 20180824)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-3999
Web: https://insurance.az.gov/
Assignment of Certificate of Deposit or Time Deposit to Arizona State Treasurer
Please type all information. File TWO originals of this form with your Certificate of Deposit or Time Deposit Receipt.
Check Deposit Type: □Ordinary □Workers’ Compensation
FULL LEGAL NAME OF COMPANY NAIC # IF APPLICABLE
STREET ADDRESS CITY STATE ZIP
hereinafter called Assignor, hereby assigns and transfers to the Treasurer of the State of Arizona (“Treasurer”) all right, title
and interest of any kind whatsoever of Assignor in and to the Assignor’s insured account in the
NAME OF FINANCIAL INSTITUTION
held in account number and identified as Certificate of Deposit or Time Deposit number
in the amount of $ dollars. Assignor agrees that this assignment carries
with it the right to the insurance of the account by the (appropriate federal insurance agency) , and includes
and gives the right to the Treasurer to redeem, collect, and withdraw the full amount of such account at any time without notice
to the Assignor. This assignment is given as security for authority to transact insurance or a related business regulated by the
Department of Insurance in the State of Arizona, and all purposes permitted under Title 20 or Title 23 as applicable. Assignor
hereby notifies the above-named financial institution of the assignment. Interest accruing to the account remains the property
of the Assignor. This assignment remains in effect until its release is authorized by the Treasurer in writing.
Dated this day of , at
BY:
SIGNATURE OF OFFICER OR PRINCIPAL TYPE NAME AND TITLE
ACKNOWLEDGEMENT OF NOTICE OF ASSIGNMENT
We acknowledge the assignment of this account to the Treasurer and have marked our records to show this assignment. We
have retained a copy of this document. We certify that we have not received a notice of lien, encumbrance, hold, claim or
other obligation against this account. We waive any current and future right of set-off against this account. We agree to release
the assigned principal funds held in this account to the Treasurer upon request. We also agree to notify the Treasurer ninety
(90) days prior to taking any action which would modify, cancel or allow the withdrawal of funds from the account
other than accrued interest.
Dated this day of , at .
NAME OF FINANCIAL INSTITUTION
STREET ADDRESS CITY STATE ZIP
BY:
SIGNATURE OF OFFICER OF FINANCIAL INSTITUTION TYPE NAME AND TITLE OF OFFICER
Subscribed and sworn before me this day of _, .
DATE COMMISSION EXPIRES NOTARY PUBLIC SIGNATURE
RECEIPT FOR SECURITY AND DIRECTION TO PAY EARNINGS
We acknowledge receipt of the assignment of principal funds held in the account described in above. The financial institution
is authorized and directed to pay interest earned to the Assignor.
Dated this day of , at Phoenix, Arizona.
BY:
ARIZONA STATE TREASURER OR AUTHORIZED REPRESENTATIVE
