Fillable Public Depositor Account Form (Nevada State Treasurer)

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Public Depositor Account Form (Nevada State Treasurer)

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Rev 12.20.2016
Public Agency
Bank or Credit Union
Agency Name
Bank Name
Contact Name
Contact Name
Phone
Phone
Email
TAX ID
Account Number
Account Name
Status
(open/closed)
Effective
Date
* Report all Time and Demand Deposits, including savings accounts, money market accounts, negotiable order or withdrawal (NOW) accounts, and certificates of deposit.
Please attach additional sheets if necessary.
Authorized Name (Public Agency) Authorized Signature (Public Agency) Date
Please complete this form and email to:
Email pooledcollateral@nevadatreasurer.gov
Questions? Call (775)684-5610
Fax: (775)684-5776
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Public Depositor Account Form (Nevada State Treasurer)

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Completed 21 July 2020

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