Pledgee Authorization Form PLEDGEE AUTHORIZATION FORM
Please list those individuals who are authorized to release securities pledged to a public entity which are held in a joint custody
account at the Federal Reserve Bank of Kansas City. This list will be used to verify the authenticity of any written, telephonic or
facsimile instructions to release pledged securities. Prease provide the name, title and signature of at least three individuals and as
many additional people as you need to account for vacations, illness, turnover, etc. If you need space for more than six names, please
fill out an additional form. If you need to change the list, please send us a revised form. The revised form must list all persons
authorized to release securities. Please call (800) 333-2883 or 881-2883 if in the Kansas City area to request additional forms.
PLEASE PRINT OR TYPE
PUBLIC ENTITY NAME: DATE: / /
PLEDGEE CBI NUMBER*:
CITY/STATE:
TELEPHONE NUMBER ( )
AUTHORIZED PERSONS (at least three names should be specified):
1.
NAME/TITLE SIGNATURE
2.
NAME/TITLE SIGNATURE
3.
NAME/TITLE SIGNATURE
4.
NAME/TITLE SIGNATURE
5.
NAME/TITLE SIGNATURE
6.
NAME/-rlTLE SIGNATURE
BY:
OFFICIAL'S NAME SIGNATURE **
TITLE
* This nine digit number can be found on the acknowledgement or joint custody receipt mailed to you at the time a pledge is made
or by contacting the Federal Reserve Bank.
** This form must be signed by an official of the public entity. For control purposes, if at all possible, we recommend that the
official not be one of the persons authorized to release securities. By signing this form, the official warrants to the Federal Reserve
Bank of Kansas City that he or she has the authority to authorize the persons listed to release pledged securities.
Return to: Federal Reserve Bank of Kansas City
Attn: Securities Services
P. O, Box 419033
Kansas City, MO 64141-6033
(800) 333-2883 or 881-2883
DEPARTMENT OF FINANCE AND ADMINISTRATION
CITY CLERK
Salina
Date:
REQUEST TO RELEASE PLEDGED SECURITIES
Federal Reserve Bank of Kansas City
Attention: Securities Services
P.O. Box 419033
Kansas City, Missouri 64141-6033
Please release from joint custody the securities described below:
Pledgor's Name:
Pledgor's CBI:
Security Identification:
CUSIP: Maturity Date:
Par Amount:
Pledgee CBI: 981-009-191
I understand that the securities listed above will be released to the
pledgor upon receipt of this release and receipt of transfer instructions
from the pledgor.
CITY OF SALINA
By:
Signature
Authorized Individual's Name