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.
Title
Title
Title
Title
Title
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.
Name
Social Security Number
Name
Social Security Number
Name
Date
Signature of Requestor
Title
Approved By
Date
Social Security Number
Name
Social Security Number
Name
Social Security Number
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