* PLEASE NOTE: USE YOUR FINANCIAL INSTITUTION’S LETTERHEAD*
Fax form to State Treasurer of Ohio (“Treasurer”): (614) 466-9948 or e-mail to:
DEPOSIT AND PLEDGE OF ELIGIBLE SECURITIES AS SECURITY
FOR THE DEPOSIT AND REPAYMENT OF PUBLIC MONEY PURSUANT TO
OHIO REVISED CODE (“ORC”) § 135.18.
(Name of Bank (“Trustee”) which is to have custody of securities)
In accordance with the ORC § 135.18, confirms that the following security (“Security”) was received and
placed for safekeeping in the public depository (“Depository”) account referenced below. This Security
is being held to secure the interest of the Treasurer pursuant to an agreement among Trustee, State
Treasurer of Ohio, and _____________________________________________________________, a
Security to be Pledged:
SECURITY DESCRIPTION: ______________________________________________________
PLEDGE AMOUNT: _____________________
(if pledging a mortgage security, enter original balance amount)
CURRENT PAR: ________________________
INTEREST RATE: ________________________
MATURITY DATE: ________________________
CURRENT MARKET VALUE: __________________________
Unless otherwise notified in writing, interest proceeds will be credited to the Depository named above.
In case of default by the Depository, the Treasurer may make a written demand upon the undersigned for
surrender of the Security described above and tender this receipt. The undersigned shall deliver the
Security to the Treasurer thereupon being discharged of all further responsibility.
By: ___________________________________________________Date: _________________________
(Authorized Officer of the Trustee)