REQUEST FOR SECURITIES TRANSACTION
TO:
Name
Title, Dept.
Campus
FROM:
Date:
Escrow Number:
(Contractor Name)
SUBJECT:
Request for Securities Transaction
We would like to (deposit, exchange, withdraw) the following securities in the above-referenced
escrow account at the State Treasurer’s Office (STO). Listed below is the required information
regarding this transaction. Please have the transaction take place by:
.
DEPOSIT:
1)
Security Name:
2)
Issue Date:
3)
Date of Maturity:
4)
Interest Rate:
5)
CUSIP Number:
6)
Security Number:
7)
Amount: $
For Book Entry securities at CITIBANK, also include the following:
8)
Delivering Broker or Bank:
9)
Delivering Agent’s DTC Number for Book Entry Municipals & Treasuries:
10)
Settlement Date (Date delivered to CITIBANK):
EXCHANGE/WITHDRAW:
1)
Security Name:
2)
Issue Date:
3)
Date of Maturity:
4)
Interest Rate:
5)
CUSIP Number:
6)
Security Number:
7)
Agent Security Being Released to: (Please include a contact person & address)
Agent
8)
Street Address
Amount: $
Contact Person
City
Zip
For Book Entry securities at CITIBANK, also include the following:
9)
10)
11)
12)
13)
Broker or Bank Securities Being Released To (Broker’s DTC Number)
Bank’s ABA Number:
Contractor’s Account Number:
Settlement Date (Date Securities Being Released):
Amount: $
Title (Authorized Signature)
Date
Construction Administrator
Date
Construction Mgmt.
704.06 • 10/06