Agency Name: Org #:
Mailing Address:
Agency Contact Name:
Contact Email Address:
Phone: Fax:
Request is hereby made to open an account in:
for the purpose of receiving and processing funds not due the State as defined by West Virginia
Code §12-2-3, which requires that all outside bank accounts be authorized by the State Treasurer.
Account Name:
Purpose: (Attach additional pages if necessary)
Authorizing Code Section:
Desired Open Date: Amount of Initial Deposit:
Bank Contact Name: Phone Number:
Email Address:
Agency FEIN:
Attach a copy of government issued business license or Certificate of Existance issued by the Secretary of State as
proof of FEIN for bank purposes.
Will the account be audited - Yes/No: If so, by whom:
Interest Bearing - Yes/No:
Source of Revenue:
Revenue Schedule (daily, weekly, seasonal, etc.):
Number of Deposits Based on Revenue Schedule:
Revenue Amount Based on Revenue Schedule:
Type of Disbursements:
Method of Disbursements (Checks, ACH, Wire):
Disbursement Schedule (daily, weekly, seasonal, etc.):
Number of Disbursements Based on Disbursement Schedule:
(Depository Name)
West Virginia State Treasurer's Office
Division of Cash Management
Request to Open an Outside Bank Account
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Disbursement Amount Based on Disbursement Schedule:
Authorized Indivuduals for Outside Bank Account:
Attach copy of driver's license or state id for bank purposes.
WVSTO Use Only
The subject request has been reviewed and is approved by the WVSTO.
Account Name: State of West Virginia
ABA: Account #:
Mail To:
West Virginia State Treasuer's Office
Attn: Cash Management - Outside Bank Accounts
322 70th Street SE
Charleston, WV 25304
Phone Number: 304-558-3599
Fax Number: 304-340-1511
I hereby certify that the above information is true and accurate to the best of my knowledge. My
signature below indicates I have read the Outside Bank Account Policies and Procedures and agree
to the terms therein. Further, I agree to provide any and all outside bank account information
requested by the Office of the State Treasurer in a timely manner.
Social Security Number
Social Security Number
Signature of Requestor
Approved By
Social Security Number
Social Security Number
Social Security Number
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