Banking Service Form
200 Piedmont Avenue, Suite 1202 West Tower, Atlanta, GA 30334 Phone (404) 656-2168, Fax (404) 657-9066
To be completed by the requesting Agency
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Action:
Initial Authorization
Modification
Account Closed
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Requesting Agency Name:
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Requesting Agency Address:
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Requestors Name:
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Requestors Phone Number:
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I certify that this bank account is in compliance with the Bank Fee Program and has prior approval from OTFS.
Yes
No
Funding Information: To be completed by the requesting Agency
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Reason for request account:
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Bank services being provided for this account:
Bank Information: To be completed by the requesting Agency
Proposed Bank Name and Branch:
Address:
Account Title:
Estimated Account Balance:
Office of Treasury and Fiscal Services Use Only
Date Received:
Recommended Action:
Recommended Date:
Bank Account Number:
Bank Account Contact Name:
OTFS Form: 100-E
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Indicates Response Required