Fillable Participation Application Form FillableV2 (Arkansas State Treasury)

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Participation Application Form FillableV2 (Arkansas State Treasury)

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PARTICIPATION APPLICATION
ARKANSAS STATE TREASURY MONEY MANAGEMENT TRUST
Please complete this form and return to the Arkansas State Treasury’s Office via email.
Email: MMTrust@artreasury.gov
Contact: STMMT Administrator (501-682-1291)
THIS FORM WILL SUPERSEDE PREVIOUSLY SUBMITTED AUTHORIZED USER
FORMS
Date: _______________________________
MEMBERSHIP DATA
Name of Participant: ________________________________________________________________________
Account Name: _____________________________________ County: ____________________________________
Address: ______________________________________ Phone: _____________________________________
______________________________________ Fax #: _____________________________________
PERSONS TO CONDUCT TRANSACTIONS – Please designate one to receive statements
Name
Phone Number
Email
Signature
BANK WHICH WILL PROCESS TRANSFERS TO AND FROM TRUST – Attach deposit slip for each account
Bank Name: _______________________________________________________________________________
Bank Address: _______________________________________________________________________________
_______________________________________________________________________________
Bank T/R Number:______________________________________________________________________________
Account Number: _______________________________________________________________________________
Name of Account:______________________________________________________________________________
Any changes to these instructions must be submitted in writing to the Office of the State Treasurer.
NOTARIZATION
(I/we) hereby make oath that (I/we) are authorized by the entity named above to enter into this agreement with the
State Treasury Money Management Trust and to transact business therewith. The entity accepts the terms and
conditions of the Trust as may be set forth from time to time by the State Treasurer in authorized written
communication. We agree to provide prompt written notification of any change in authorized personnel.
Name (Print or Type): Title: Signature of Authorized Officer(s):
____ ___________________________________ _____________________ ________________________
_______________________________________ _____________________ ________________________
; State of Arkansas ; County of , 20day of Sworn before me this ________ ________________ ___ ______________
Seal: Date My Commission Expires:Notary Public Signature: ____________________________ ______________
_____________________________________________________________________________________________
For Office Use Only
Date Received:Account Number Assigned: _______________________________ ______________________
APPLICATION INSTRUCTIONS
A copy should be retained for your records. Complete the lines on the application as follows:
Date is current date on which application is completed.
MEMBERSHIP DATA
Name of Participant is the name of the entity for which the account(s) is being opened.
Account Name is the name in which the participant wishes the Trust to carry its account. Names may reflect the purpose for
which funds are being invested.
Address is the mailing address to which all statements and other mailed communication is to be directed.
County is the name of the county in which your entity is located.
Phone is the telephone number at which an authorized person of your unit can be reached regarding STMMT matters.
Fax Number is the number of the facsimile machine convenient to your operation (if applicable).
PERSONS TO CONDUCT TRANSACTIONS
Name, Phone, Email, and Signature of the individuals of your unit who are designated to transact business in the STMMT.
Please indicate with an asterisk the person to whom statements should be mailed.
BANK WHICH WILL PROCESS TRANSFERS TO AND FROM STMMT
Bank Name is the bank from which you will make deposits and to which withdrawals from the STMMT will be sent.
Bank Address is the mailing address of the bank named above.
Bank Transit/Routing Number is the routing number of the bank named above.
Account Number is the number of your account at the bank named above.
Name of Account is the designated name in which the bank named above carries your account.
NOTARIZATION
Name, Title, and Signature of the authorized officer(s) entering into this agreement with the STMMT for the participant.
Officer(s) should sign application before a notary public.
Notary Public Signature, Dates and Seal must be completed by a notary public in order for your application to be accepted.
NOTE: Upon receipt and acceptance of this application by the STMMT office, you will be notified of
your account number. You will have to have this number in order to transact business in the STMMT
and the identity of the number should be restricted to authorized personnel.
Should there be any changes to the information on this application, an Information Change Form should
be completed immediately.
PARTICIPANT INFORMATION REVISION FORM
ARKANSAS STATE TREASURER MONEY MANAGEMENT TRUST
Please complete this form and return to the Arkansas State Treasurer’s Office via email.
Email: MMTrust@artreasury.gov
Contact: STMMT Administrator (501-682-1291)
Complete appropriate sections of form. Put N/A for sections that are not applicable to your change.
1. Account #: _____________________________________
2. Date: _____________________________________
MEMBERSHIP DATA
Current
Change To
3. Entity Name: ____ ________________________________ ________________________________
____4. Account Name: ________________________________ ________________________________
____5. Address: ________________________________ ________________________________
____________________________________ ________________________________
____6. Phone Number: ________________________________ ________________________________
____7. Fax Number: ________________________________ ________________________________
PERSONS TO CONDUCT TRANSACTIONS
(Typed/Printed) Name Signature
Title
8. Add: ______________________________ _____________________ ____________________
9. _________________________________ _____________________ _________________
10. _________________________________ _____________________ _________________
(Typed/Printed) Name Signature Title
11. Delete: ____ _____________________________ _____________________ _________________
12. _________________________________ _____________________ _________________
13. _________________________________ _____________________ _________________
BANK INFORMATION
Bank Name and Address Account # and Bank T/R#
Name of Bank Account
14. Add: ____ _____________________________ _____________________ _________________
15. _________________________________ _____________________ _________________
Bank Name and Address Account # and Bank T/R# Name of Bank Account
16. Delete: _________________________ _________________________ _____________________
_________________________
17. _________________________ _________________________ _____________________
_________________________
AUTHORIZED OFFICER(S)
The following individuals are now the authorized financial officer(s) charged with the custody of the funds to
participate in the STMMT:
(Typed/Printed) Name Signature
Title
18: _________________________ _________________________ _____________________
19. _________________________ _________________________ _____________________
NOTARIZATION
(I/we) hereby make oath that (I/we) are authorized by the entity named above to enter into this agreement with the
State Treasury Money Management Trust and to transact business therewith. The entity accepts the terms and
conditions of the Trust as may be set forth from time to time by the State Treasurer in authorized written
communication. We agree to provide prompt written notification of any change in authorized personnel.
Name (Print or Type): Title: Signature of Authorized Officer(s):
_______________________________ _________________________ ____________________________
_______________________________ _________________________ ____________________________
Sworn before me this ________ day of ________________ , 20___; County of ______________; State of Arkansas
Notary Public Signature: ____________________________ Date My Commission Expires:
SEAL
PARTICIPANT INFORMATION REVISION INSTRUCTIONS
Please keep a copy for your records. Complete the blank lines on the change form as follows:
1. STMMT Account Number is the account number that was assigned to you for STMMT 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 STMMT to carry its account.
5. Address is the mailing address where you want your STMMT 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 governmental entity to perform
STMMT 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 STMMT. 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 STMMT transactions may be added by inserting their typed/printed name, and
affixing an original signature and current job title on the indicated blanks on items 8 through 10.
11. Persons who will conduct STMMT 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 STMMT account, insert the
bank name, address, account number and transit routing number, and name of account. (Name of account if
the name under which this bank account 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 STMMT
account, provide the bank name, address, account number and bank transit routing number, and name of
account.
Please provide all data requested in items 20 through 25.
18. Authorized Officers are those individuals or officers charged by the governing body of your entity with
custody of the funds associated with this STMMT 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 STMMT account.
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 STMMT staff at (501) 682-1291.
DISCLOSURES AND DISCLAIMERS
ARKANSAS STATE TREASURY MONEY MANAGEMENT TRUST
Please complete this form and return to the Arkansas State Treasury’s Office via email.
Email: MMTrust@artreasury.gov
Contact: STMMT Administrator (501-682-1291)
Investment Disclaimer
Arkansas State Treasury Money Management Trust deposits and interest earnings are not
guaranteed or insured by any bank, the State of Arkansas, the Federal Deposit Insurance
Corporation, the Federal Reserve Board, or any other state or federal agency. Arkansas State
Treasury Money Management Trust deposits involve certain investment risks. Participants
should be aware of their financial situation and risk tolerance level at all times. Yield and total
return may fluctuate and are not guaranteed. Prior to making the decision to invest in the Money
Management Trust, potential participants should consider market risk, interest rate risk, and
credit risk in determining whether an investment is appropriate. Participants bear the sole
responsibility for deciding if investing in the Arkansas State Treasury Money Management Trust
is suitable and appropriate. Participants are also responsible for reviewing their own governing
statutes, regulations, and policies to determine whether it is legal or appropriate to invest in the
Arkansas State Treasury Money Management Trust. Past performance is no guarantee of future
results, and current performance may be lower or higher than previous performance.
Forward Looking Statements
Presentations made by and on behalf of the Arkansas State Treasury Money Management
Trust may contain forward-looking statements. These statements reflect current beliefs and
conditions, as well as assumptions made by, and information available to, Arkansas State
Treasury Money Management Trust. Forward-looking statements are not guarantees of future
performance and involve risks and uncertainties. Actual future results and developments could
differ materially from those set forth in these statements due to various factors. These factors
include, among other things: changes in financial markets, fluctuations in the general economy
and competitive situation and financial markets. Arkansas State Treasury Money Management
Trust does not undertake any obligation to update forward-looking statements.
Authorized by:
______________________________________ ______________________________________
Signature Title
______________________________________ ______________________________________
Please Print Name Date
__________________________________________________________________
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Participation Application Form FillableV2 (Arkansas State Treasury)

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Completed 26 July 2020

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