1. Fund Account Number is the account number that was assigned to you for Fund transactions.
2. Date is the current date on which the form is completed.
For items 3 through 7, please provide the old data for reference as well as the new data you want to
authorize.
3. Entity Name is the name of your agency, local government, or political subdivision.
4. Account Name is the name under which the participant wishes the Fund to carry its account.
5. Address is the mailing address where you want your Fund correspondence directed. Please include street or post
office box number, city, state, and zip code.
6. Phone number is the telephone number where a person authorized by your government entity to perform Fund
transactions can be reached.
7. Fax Number is the telephone number of a facsimile copy machine that is convenient to your personnel
authorized to do business with the Fund. Insert “N/A” if this does not apply to you.
For items 8 through 19, please indicate only the information that you want added and/or deleted.
8. Persons who will conduct Fund transactions may be added by inserting their typed/printed name(s), and affixing
an original signature(s) and current job title(s) on the indicated blanks on items 8 through 10.
11. Persons who will conduct Fund transactions may be removed by inserting their typed/printed name(s) and job
title(s) on lines 11 through 13.
14. If you wish to add a bank account to be authorized to receive funds from your Fund account, insert the bank
name, address, account number and transit routing number, and name of account. (Name of account is the name
under which this bank is held.) Attach a bank account deposit form for each account you wish to add.
17. To remove a bank account from the list of bank accounts authorized to receive funds from your Fund account,
provide the bank name, address, account number and bank transit routing number, and name of account.
18. Authorized Officers are those individuals or officers charged by the governing body of your entity with custody
of the funds associated with this Fund account. Please provide the typed or printed name, original signature, and
title of those individuals who are charged with the responsibility of the funds source to this Fund account.
Please provide all data requested in items 20 through 25.
20. Authorized Officer is the individual who is responsible for these funds and responsible for designating how
transactions will be authorized. Please provide an original signature.
21. Please type or print the name of the individual whose signature appears on line 20.
22. Please provide the title of the individual who signed on line 20.
23. The notary statement, signature, and seal are to be completed by an Arkansas notary. Please provide
notarization of all change forms.
Any questions about this change form may be addressed to the Fund staff at (501)682-1291.
