E-mail completed form to: agency.collateral@tos.ohio.gov or Fax to: (614) 466-9948
The Treasurer of State of Ohio requires a designated individual from the agency on site at the Trust Department to pick up the
securities being released. This designated individual must be pre-appointed by the agency with an original signature on file.
Agency: ________________________________________ Division: _____________________________________
Contact: ________________________________________ Telephone: ___________________________________
Agency Designee Signature: _________________________________________________________________________
Note to Agency: If a pledge increase or decrease of collateral is required, please use the Pledge Form to indicate the
existing record to update.
Securities to be Released
For TOS Use
Record #
Pledgor
Certificate Number
or CUSIP
Issuer/Bank
Pledge Amount
Treasurer of State of Ohio
30 E. Broad Street, 9
th
Floor
Columbus, Ohio 43215-3461
Treasurer’s Office Contacts
Elizabeth McAndrew (614) 644-1285
Jane Matson (614) 644-1275
Robert Sprague, Treasurer
of State of Ohio
Trust Department Collateral Section
Agency Securities Held in Trust Request for Release Form
Treasurer of State of Ohio
Trust Department Collateral Section
Instructions for completing the Securities Held in Trust Request for Release Form
E-mail completed form to: agency.collateral@tos.ohio.gov or Fax to: (614) 466-9948
Treasurer’s office personnel will contact the agency designee to arrange a date and time to schedule the
appointment.
Agency The name of the agency for which the security is in trust.
Division The agency division for which the security is in trust.
Contact The person from the agency requesting the release.
Telephone The phone number for the contact who is sending the request.
Agency Designee Signature The individual who is pre-appointed by the agency with an original
signature on file with the Treasurer of State of Ohio.
Securities to be Released section
For TOS Use Record # Please leave this column blank.
Pledgor The Pledgor of the security.
Certificate Number or CUSIP The security identifier.
Issuer/Bank The entity where the security is held.
Pledge Amount The amount held by the state to be released.
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