02/2019
State Treasury Asset Reserve
New Trust Account Form
I. APPOINTMENT OF TRUSTEEIf you wish to authorize a bank, investment advisor, or trust company to purchase
and redeem investments in STAR Ohio on your behalf, and to receive all communications from STAR Ohio on your behalf,
complete this section. Any redemptions made by such party on your behalf will be made only to your account of record.
Such party may not change your account of record.
Name of bank or trust company: _____________________________________________________________ (“Trustee”)
Address: ___________________________________________________________________________________________
___________________________________________________________________________________________
Attention: _________________________________________________
(Name of contact person) Email Address
Telephone______________________________________ Fax (if any) __________________________________
Email Address ______________________________________________________________________________
The undersigned represents and warrants that the participant has full right, power and authority to, and hereby does,
appoint the aforementioned Trustee as its agent for purposes of purchasing and redeeming investments in STAR Ohio and
receiving all communications to the participant from STAR Ohio. The undersigned acknowledges that all communications
by STAR Ohio to the participant will be made only to the Trustee, unless STAR Ohio is otherwise advised in writing by the
participant.
____________________________________ ____________________________________
Name of Participant Address of Participant
____________________________________ ____________________________________
Contact Person at Subdivision Telephone Number of Participant
_______________ _______________________ _______________________ ___________________
Date Authorized Officer of the Subdivision Signature Title
The undersigned, being a duly authorized officer of the Trustee, hereby accepts the foregoing appointment and agrees to
promptly provide to the participant, at the address shown in Section I hereof or such other address provided in writing by
the participant, all communications from STAR Ohio received by the Trustee on behalf of the participant. The undersigned
also represents and warrants that he/she has received and reviewed the Informational Booklet.
_____________ ______________________________ ______________________________ _____________
Date Authorized Officer of the Trustee Signature Title
All accounts must be opened in the name of the political
subdivision or the State and executed by an officer thereof.
If you need assistance in filling out this form, representatives
are available toll-free: 1-800-648-STAR (7827)
Make all checks payable to: STAR Ohio
Mail checks to: STAR Ohio
PO Box 46794
Cincinnati, OH 45246
Fax form to: 614-923-1149
Mail form to: STAR Ohio
PO Box 7177
Dublin, OH 43017
Email form to: info@starohio.com
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