95 Pledge Authorization FEDERAL RESERVE BANK OF KANSAS CITY
PLEDGEE AUTHORIZATION FORM
Please list the individuals authorized to release securities pledged to a public entity and held in a joint custody
account at the Federal Reserve Bank of Kansas City. This list will be used to verify the authenticity of instructions to
release pledged securities (written, telephoned or faxed). Please provide the name, title and signature of at least three
individuals and as many additional people as you need to accommodate vacations, illness, turnover, etc. If you need
space for more than six names, please fill out an additional form. This form must be signed by an officer of the public
entity. If possible, we recommend that the official not be included on this list as one of the persons authorized to release
securities. By signing this form, the officer warrants to us that he or she is authorizing the persons listed below to release
pledged securities.
If you need to change your list, please send us a revised form. Any changes to your form must include ali
authorized staff. Any person NOT on the most recent list will NOT be allowed to conduct transactions involving
securities. If you would like to request additional forms or if you have questions, please call (800) 333-2883 or 881-2883
in the Kansas City area.
PLEASE PRINT OR TYPE
PLEDGEE CBI NUMBER*:
TELEPHONE NUMBER: ( ~/
AUTHORIZED PERSONS (at le~t ~ n~es should ~ specified; if ~ese individu~s ~e not at ~e numar listed above, ple~e
provide ~ ~temate phone number.)
N~itle Si~ature Alte~te Phone
N~e~itle '
N~e~ifle ~ / Signature Alternate Phone
Name/Title Signature Alternate Phone #
Name/Title Signature Alternate Phone #
Name/Title Signature Alternate Phone #
Officer's Name/Title ' Signature Alternate Phone #
* This nine digit number can be found on thc acknowledgement or joint custody receipt mailed to you at thc time a pledge is made or by contacting thc Federal
Reserve Bank.
Return to: Federal Reserve Bank of Kansas City
Attn: Wholesale Payments & Fiscal Services
P.O. Box 419033
Kansas City, MO 64141-6033
(800) 333-2883 or 881-2883