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:
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:
