Special Purpose Investment Account

SPECIAL PURPOSE INVESTMENT ACCOUNT

NEW ACCOUNT REQUEST FORM

The following entity would like to open a Special Purpose Investment Account:

Organization’s Name:
Organization’s Address:
Organization’s Phone Number:

Any board, association, or entity created by the state constitution or by law may participate in the Special Purpose Investment Accounts. Please indicate how the entity was created:

State Constitution – Section:
Florida Statute – Chapter:

Is this organization currently a participant in the Special Purpose Investment Account? Yes_____ No_____

If yes, please supply the entity ID (the first 4 numbers of your SPIA account number):______

And, will the Authorized Personnel be the same as the existing account(s)? Yes ______No ______

Comments:
Executed on:
Signature:
Name and Title:
Email address:

Once this form has been received and approved by the Florida Division of Treasury, the person executing this form will receive an agreement. When we receive the fully executed agreement, please give us ten business days to open the account.

Mail completed form to:

Department of Financial Services

Division of Treasury

Bert Wilkerson, Chief

Bureau of Funds Management

200 E. Gaines Street/Hermitage

Tallahassee, FL 32399-0344

Should you have questions, please contact Cherie Jeffries at 850-413-2779. Thank you.

Updated 12/1/09