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HomeMy WebLinkAboutLGIP Participant Acct. Maint. Form 10-11-13 LGIP Participant Account Maintenance Form (One form must be completed for each agency account.) 1) Account Information: 2) Contact Information: New Account Change Existing Acct (please check one) Address: 105 Polk Ave Agency Account#: 121042 PO Box 326 Participant Name: City of Cape Canaveral City/State/Zip: Cape Canaveral,FL 32920 Account Name: Phone: 321-868-1234 Fax: 321-868-1248 Banking Information: 3) Bank WIRING Instructions: ❑ Check if Change Beneficiary Bank Name: ABA/Routing Number: Bank Address: Account Number: I "Complete this section below ONLY if your bank is not on-line with the Federal Reserve and utilizes a correspondent bank for wires** Receiving Bank Name: (Fed Bank) ABA/Routing Number: (Fed Bank) Bank Address: Beneficiary Information: Beneficiary Account: 4) Bank ACH Instructions: (Complete if plan to utilize ACH option) ❑ Check if Change Beneficiary Bank Name: ABA/Routing Number: Bank Address: Account Number: 5) Name of ALL Persons Authorized to Transmit/Withdraw Funds: 1 Check if email NAME EMAIL ADDRESS(required field) changed David L. Greene d.greene @cityofcapecanaveral.org ❑ Angela A. Apperson a.apoersont cityofcapecanaveral.org ❑ Rocky Randels r.randels Ocityofcapecanaveral.org ❑ 6) Name of ALL With 'View Only'Website Privilege:(full access to website but may NOT conduct business) Check if email NAME EMAIL ADDRESS(required field) changed John Deleo j.deleocityofcaDecanaveral.orq ❑ 7) Name,Title, Email and Signature of Persons Authorized to Notify the SBA of Changes in Account Information: Name: David L. Greene Title: Cit Manager Email: d.greene©cityofcapecanaveral.org Signature: aq....41 '� /•l. AJzz ,..t. Name: Rocky Randels Title: Mayor Email: r.randels©cityofcapecanaveral.org Signature: Qe��V„` (_�,,,,,, ,pf�,a,,, Name: Title: Email: Signature: Please select 8) Number of Authorizing Signatures Required to Change Account Information. r ® One O Two PLEASE NOTARIZE FORM AND RETURN THE ORIGINAL TO BE PROCESSED 9) This section MUST be signed by an Official 10) STATE of FLo �\ COUNTY OF /i ,;( ¢R1� authorized in the Resolution OR listed on the previously submitted Participant Account The foregoing instrument was acknowledged before me Maintenance Form as Authorized to Notify the SBA of this //e.21 day of Oc etr ,20/3 , Changes in Account Information byZ44,,dL•&termli Oel wbei's who is/arepersonally known to me or who has produced (DO,..;j —I. /1 A 4j..HJV • _ as identification AUTHORIZED SIGNATURE#1 - . - City Manager (�ircle. GOFOR H TITLE y"�p.¢� Notary Public-State 0 �•��±i My Cof EllPlfe$May 16, AUTHORIZED SIGNATURE#2(IF REQUIRED) 1:),1-...:1E3.1' Commission#EE 666939 Notary P State of Florida s . `e Donded Through National Notary Assn. TITLE ■y ommission expires: " /- 2 / 7 DATE Authorized signers must complete the Disclosure Statement on page 2(required by FS 218.407(1)) I FOR STATE BOARD OF ADMINISTRATION USE ONLY Initial input Date FC Approval Date Mgt approval Date Form update 6/10/2012 Page 1 of 2 1 P i 1 I i TM I .,',' 4* PRIME s.r 1"v t , r 1 s,-,m,,ICE' I-Ole 1'13 i3 IC}'1 f DS Disclosure Statement For Participation in the Local Government Surplus Funds Trust Fund (Florida PRIME) This D/isc losure S t( ,_-3027,1:3).is made I entered into by and between the State Board of Administration of Florida(the"SBA")and z-,.% Cam! fj ov'�V' �! (the"Paticipanf')_ i WHEREAS,Chapter 218.405,Florida Statutes,creates a public finals investment pod to which any local government of the State of Florida may delegate, by Authorizing Resolution,the authority to hold legal title as custodian and to make investments purchased with local surplus funds; WHEREAS,the SBA is authorized pizsuant to Chapter 218.409,Florida Statutes to receive,transfer,and disburse surplus money and securities belonging to"units of local governments"of the state(as defined herein); WHEREAS,the Local Government Surplus Funds Trust Fund(Florida PRIME)is a public finds investment pool,which funds are invested in certain eligible investments as more fully described in the enrollment materials; WHEREAS,the SBA is authorized pursuant to Section 215.44,Florida Statutes to invest the finds of state agencies,state universities and colleges and direct support organizations of any of the foregoing in Florida PRIME; WHEREAS,the Participant has determined that it is authorized to invest in Florida PRIME created under the Florida Statutes and has adopted the required Authorizing Resolution to permit the SBA to invest and reinvest finds of the Participant in Florida PRIME; WHEREAS,the Participant acknowledges that the SBA is not responsible for independently verifying the Participant's authority to invest under the statutes; WHEREAS, the Participant acknowledges that the performance of Florida PRIME is not guaranteed by the State of Florida, the SBA or any other governmental entities;and NOW THEREFORE,for and in consideration of the mutual promises,covenants and agreements herein contained,the receipt and sufficiency of which are hereby acknowledged,the parties hereto agree with each other as follows: The Disclosure Statement. The Participant must execute this Disclosure Statement, an Authorizing Resolution and a completed Participant Account Maintenance Form designating person(s)to serve as Authorized Representatives of the Participant before depositing any funds into Florida PRIME. Aduaowledgemeut of Disclosure.The following signatory is a duly appointed,acting,and qualified officer of the Participant,who,in the capacity set forth above is authorized to execute this Statement_ Further the Participant hereby acknowledges receipt and review of these enrollment materials which includes the New Participant Euollment Guide,Authorizing Resolution,this Disclosure Statanent,Florida PRIME Investment Policy Statement,applicable Rules, and other historical financial information also posted on the Florida PRIME website. At the SBA's discretion,modifications to these documents may be posted on the Florida PRIME website. The Participant will have up to 45 days to withdraw their finds from the PRIME or the modifications will be deemed accepted by th7icipant - 1 .5'./ a 6NA V 6/V/ /0 /0 a PARTICIPANT NAME: /� ��Ce ft SIGNATURE TITLE ,D Z. G PRINTED NAME: A:‘g t6/.4 o c > d,64j e pvr4l.o� Page 2of2 ®Copyright 2011 i 1 t 1 i i 1