2008-45RESOLUTION No. 2008 -45
Citens Bank Chart€�IJne
GOVERNMENT BANKING AND NOT - FOR - PROFIT DIVISION
CERTIFICATE OF DEPOSIVREPURCHASE AGREEMENT APPLICATION
ACCOUNT REGISTRATION
Municipal ® Individual ❑ Other ❑ Describe "Other":
This account is ® is NOT ❑ EXEMPT from 1099 tax reporting requirements.
CIISTnMFR INFARMATInIJ
Name: Tax ID #:
Village of Buffalo Grove 36- 2525051
Contact: Daytime Telephone
Scott Anderson 847.459.2509
Street Address: Email Address for confirmations:
50 Raupp Blvd sanderson vb .or
City, State, Zip
Buffalo Grove, IL 60089
We will request our principal and /or interest wired out of Citizens /Charter One Bank on
® YES
occasion. If yes, please attach authorized wire instructions on your letterhead.
Village Treasurer Date
❑ NO
(please check box at right)
AUTOMATIC DEPOSIT/WITHDRAWAL AUTHORIZATION
I (we) hereby authorize and request RBS Citizens N.A. DBA Charter One (The Bank) to make payment of amounts representing the
proceeds of investments and other transactions entered into by me (us) through the Government Banking Division, and to secure payment
for the cost incurred in connection with effecting said investments and other transactions by initiating corresponding credit or debit entries
to my (our) account(s) designated below, respectively. I (we) also hereby ratify any telephone instructions which may be given pursuant to
this authorization and agree to hold harmless The Bank for any loss, liability, damages, cost or expense of any nature associated with
actions of Citizens based upon this authorization or said telephone instructions.
The following account(s) is /are to be credited /debited in accordance with the foregoing authorization:
AC1 — Primary DDA
AC3 — Primary SAV
❑ Bank Clearing Acct
AC2 — Secondary DDA
AC4 — Secondary SAV
Authorized
Signature:
Date
PLEASE READ CAREFULLY BEFORE SIGNING
I certify under penalties of perjury (1) that the Social Security or Taxpayer Identification Number provided above is correct, and
(2) that the IRS has never notified me that I am subject to backup withholding, or has notified me that I am no longer subject to -T•
such backup withholding (3) 1 am a U.S. person (including a U.S. resident alien) (Note: if part (2) is not true, please strike
out that part before signing.)
Authorized Customer Signature:
Authorized Customer Signature:
Village President Date
Village Manager . Date
Authorized Customer Signature:
Authorized Customer Signature:
nance Director Date
Village Treasurer Date
Number of Signatures Required: 1
Note: If more than 4 authorized signers, please add listing on
letterhead to include name, title and signature.
Bank Representative
Date:
Signature:
CDapplform 7/27/2007
00 f
VILLAGE OF
BUFFALO GROVE
Fifty Raupp Blvd.
Buffalo Grove, IL 60089 -2100
Phone 847 - 459 -2500
Fax 847 - 459 -0332
0
If an authorized signer requests principal and/or interest to be wired out of
Citizens /Charter One Bank, please send to the following account.
Buffalo Grove Bank & Trust
Account Number: 7520001695
ABA Number: 071926184
In addition to the authorized signers listed on the Certificate of Deposit/Repurchase
Agreement Application, please add the Assistant Finanpe Director as a signer.
Authorized Customer Signature:
Date: �